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HX641 26366 

RC142.H73  1907     Etiology  of  erysipel 


RECAP 


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ETIOLOGY  OF  ERYSIPELAS. 

ITS   REI.ATION    TO   THE    NASAL   CAVITIES   AND    ITS   DESTRUCTIVE 
EFFECTS  UPON  THE  EYE. 


By  C.  R.  Holmes,  M.  D., 
Cincinnati,  O. 


Reprinted  from  the  Annals  of  Otology,  Rhinology 
and  Laryngology,  September,  19021 


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ETIOLOGY  OF  ERYSIPELAS. 

its  rei.ation  to  the  nasal  cavities  and  its  destructive 
e]ffects  upon  the  eye. 

By  C.  R.  Holmes,  M.  D., 
Cincinnati,  O. 


Erysipelas  is  treated  of  systematically  in  works  on  General 
Medicine,  General  Surgery  and  Dermatology.  It  is  an  im- 
portant and  serious  disease  and  merits  the  attention  which 
these  authors  give  it.  Although  a  germ  disease  it  still  prevails 
extensively  in  this  latter  era  of  asepsis  and  antisepsis,  invad- 
ing the  best  equipped  and  best  managed  hospitals,  and  the 
cleanest  and  most  elegant  private  houses,  and  even  occurs 
spontaneously  and  without  apparent  cause  in  absolutely  new 
hospitals.  If  you  will  read  the  paragraphs  that  treat  of  the 
etiology  of  this  disease  in  the  works  that  I  have  referred  to, 
you  will  see  that  there  is  some  important  thing  in  its  causa- 
tion that  is  unexplained  or  that  an  assumption  is  made  that  is 
not  borne  out  by  the  facts  as  they  are  available  to  us  today. 
The  word  "idiopathic" — now  almost  obsolete  in  every  depart- 


2  ETIOLOGY  OF  ERYSIPEI.AS. 

ment  of  medicine — still  appears  in  their  pages.  They  feel  the 
necessity  of  apologizing  for  this  word,  however,  and  explain 
that  this  must  be  taken  to  mean  that  the  specific  germ,  intro- 
duced from  without,  gains  entrance  to  the  body  through  a 
wound  so  slight  as  to  have  been  unnoticed  or  so  transient  as 
to  have  been  healed  and  invisible  before  the  onset  of  the 
erysipelas.  In  short,  the  implication  almost  invariably  con- 
tained in  their  articles  is  that  the  infection,  the  identity  of 
which  has  now  been  established  for  many  years,  is  brought 
mysteriously  to  the  patient  from  without — either  air  borne 
through  the  infected  atmosphere  of  a  hospital  ward,  or  on 
the  hands  or  instruments  or  clothing  of  the  surgeon.  In  many 
instances — indeed,  in  a  great  many  instances — this  explana- 
tion is  appealed  to  because  no  other  is  within  the  knowledge 
of  the  authors — but  recent  studies  have  brought  me  to  the 
conclusion  that  there  is  a  vast  mass  of  literature  bearing  upon 
this  very  mystery  that  it  is  now  time  to  bring  together  and 
»ay  before  the  general  physician  and  surgeon  and  dermatolo- 
gist, that  they  may  be  enabled  to  penetrate  the  mystery  and 
advise  their  students  of  the  most  important  source  of  the 
erysipelatous  infection,  so  that  an  attempt  at  prophylaxis  will 
deliver  into  the  hands  of  the  rhinologist  and  aurist  a  class  of 
cases  that  we,  unfortunately,  too  often  see  only  after  serious 
damage  is  imminent  or  has  already  been  done.  I  am  referring 
to  the  literature  of  Rhinology,  Otology  and  Ophthamology. 
These  special  branches  are  not  often  carefully  studied  by  the 
writers  on  the  general  subjects  already  referred  to  and  that 
they  should  have  missed  the  significant  articles  scattered 
through  the  magazines  of  five  languages — ^especially  when  the 
American  literature  contains  but  scanty  reference  to  the  mat- 
ter— is  not  to  be  wondered  at. 

That  we  may  forge  an  absolutely  complete  chain  of  evi- 
dence, I  beg  that  you  will  allow  me  to  take  it  up,  link  by  link ; 
and  therefore  we  must  establish,  first,  what  erysipelas  really 
is. 

Erysipelas  is  an  acute,  infectious,  contagious  disease,  evi- 
dencing itself  by  a  characteristic  inflammation  of  the  skin  and 
mucous  membrane  and  occasionally  the  subcutaneous  tissues, 
with  a  tendency  to  spread  by  continuity  of  tissue,  and  with 
systemic  disturbances  varying  from  very  mild  to  very  profound. 
It  undoubtedly  has  a  tendency  to  spontaneous  recovery  even 
in  severe  cases. 


KTIOI.OGY  OF  ERYSIPELAS.  3 

The  exciting  cause  of  erysipelas  is  a  streptococcus — indeed 
we  may  now  say  the  streptococcus.  "Streptococci  are  most 
frequently  encountered  in  their  parasitic  abode."  Though 
capable  of  existing  for  a  short  time  outside  of  the  animal  body, 
their  slow  growth  on  culture  media  and  their  short  lives,  point 
■to  direct  transference  from  body  to  body.  Although  these 
characteristics  are  not  absolutely  uniform,  I  beg  you  to  ob- 
serve that  they  militate  strongly  against  the  idea  that  ery- 
sipelas is  an  air  borne  disease,  and  on  this  important  point  I 
will  submit  to  you  further  evidence  presently. 

Streptococci  are  subject  to  many  variations  in  form.  They 
appear  as  diplococci,  in  chains  of  from  four  to  six  smaller 
cocci,  and  in  longer  chains  with  both  large  and  small  segments. 
There  is  no  apparent  specific  difference  between  streptococcus 
longus,  streptococcus  brevis,  streptococcus  conglomeratus, 
streptococcus  gracilis  and  streptococcus  involutus,  since  com- 
paratively slight  changes  in  culture  media  or  a  sojourn  in  an 
animal  organism  (and  this  is  a  very  important  point  in  our 
study  of  this  subject)  can  change  the  morphologic  characters 
of  the  organism.  The  rate  of  growth  on  artificial  media  dif- 
fers in  streptococci  from  different  sources,  but  all  are  of  com- 
paratively slow  growth.  The  virulence  of  streptococci  from 
different  sources  also  differs  most  markedly,  not  only  in  trans- 
ferring the  cocci  from  animals  of  one  race  to  those  of  another, 
but  in  transferring  from  animal  to  animal  of  the  same  race. 
In  other  words,  environment,  the  culture  medium  employed, 
may  increase  or  decrease  the  virulence  of  the  germ  and  its 
toxins.  Streptococci  are  pus  producers.  They  may  be  associ- 
ated with  all  stages  of  pyogenic  infection  from  local  inflam- 
mation to  general  septicemia.  They  are  encountered  in  inflam- 
mations of  all  mucous  and  serous  membranes,  in  bones  and  in 
such  organs  as  the  liver  and  the  brain.  Among  other  infections 
they  are  found  either  alone  or  combined  with  other  organisms 
in  spread'ng  phlegmon  and  cellulitis,  anginas,  lobular  pneu- 
monia, synovitis  and  osteomyelitis,  lymphangitis,  pleuritis,  per- 
itonitis and  peurperal  septicaemia.  It  was  formerly  thought 
that  the  streptococcus  of  Fehleisen  (streptococcus  erys-pelatis) 
was  specifically  different  from  those  concerned  in  other  inflam- 
mations. For  instance,  John  Collins  Warren  (71),  writing  on 
erysipelas  in  1894,  said  "Fehleisen  concludes,  from  his  obser- 
vations, that  the  erysipelas  coccus  is  a  specific  microbe  which 
will   ahvays   reproduce   the   disease   when   inoculated    even    in 


4  ETIOI.OGY  OF  ERYSIPELAS. 

the  smallest  quantities.  .  .  .  The  question  of  the  identity 
of  the  erysipelas  coccus  with  the  streptococcus  pyogenes  has 
frequently  been  raised  and  authorities  are  not  yet  entirely 
agreed  upon  this  point.  The  coccus  of  erysipelas  is  larger 
than  the  streptococcus.  .  .  .  Many  modern  observers  con- 
cede that  the  erysipelas  coccus  causes  not  only  erysipelas,  but 
also  abscess,  but  many  others  believe  that  when  suppuration 
occurs,  it  is  due  to  pyogenic  cocci  which  have  become  inoc- 
ulated secondarily,  and  that  suppuration  is  therefore  merely 
a  complication  of  the  disease.  Experimental  inoculation  with 
erysipelas  cocci  has,  in  the  hands  of  one  observer,  always  pro- 
duced erysipelas,  while  inoculations  with  the  streptococcus 
produced  phlegmonous  inflammation." 

Since  this  was  written,  however,  it  has  been  satisfactorily 
demonstrated  that  the  streptococcus  of  erysipelas  may  become 
pyogenic  and  the  streptococcus  pyogenes  may  produce  a 
characteristic  erysipelatous  inflammation  of  the  skin,  and  we 
find  one  of  the  standard  textbooks  of  the  day  on  pathology 
(58)  declaring  that  "the  conditions  which  they  induce  depend 
upon  the  route  by  which  they  gain  access  to  the  body,  and 
especially  upon  their  virulence  which  may  be  exalted  to  an 
extraordinary  degree  by  certain  conditions  of  cultivation  and 
passage  through  animals.  In  short,  it  has  been  shown  that 
the  activity  of  a  streptococcus,  which  only  causes  abscess,  may 
be  exalted  to  a  virulence  by  which  erysipelas,  purulent  infiltra- 
tion or  fatal  septicemia  results.  These  experiments  serve  to 
sustain  the  views  as  to  the  common  ancestry  and  close  rela- 
tionship of  the  various  streptococci  as  indicated  by  morpho- 
logic and  physiologic  considerations,  and  to  emphasize  the 
.desirability  of  considering  them  as  a  single  group.  Besides 
their  more  active  manifestations  streptococci  may  lie  latent." 
One  of  the  most  important  studies  that  led  to  the  setting  forth 
of  this  modern  dictum  was  that  of  Fraenkel  (72)  who  report- 
ed to  the  Hamburg  Society  of  Physicians  that  from  the  pus 
contained  in  abscesses  that  had  developed  in  the  course  of 
an  attack  of  erysipelas,  he  had  been  able  to  cultivate  an  or- 
ganism that  corresponded  to  the  streptococcus  erysipelatis.  He 
had  also  observed  a  case  in  which  the  development  of  facial 
erysipelas  was  ascribed  to  infection  from  a  felon  in  the  pus 
of  which  streptococci  were  found.  In  a  case  of  extensive 
facial  erysipelas,  there  was  also  suppuration  of  the  subcu- 
taneous tissues  of  the  greatly  swollen  eyelids  and  of  the  inter- 


ETIOLOGY  OF  ERYSIPEIvAS.  5 

muscular  and  intramuscular  tissues  of  the  neck.  In  the  pus 
and  in  the  edematous  fluid  streptococci  were  foundd  micro- 
scopically and  by  culture.  In  experimental  results  it  appeared 
that  the  streptococcus  produced  at  one  time  lymphangitis  or  a 
phlegmon,  at  another  erysipelas  or  peritonitis.  He  had  suc- 
ceeded in  inducing  erysipelas  by  injections  of  streptococcus 
pyogenes  into  the  ears  of  rabbits,  and  he  had  also  occasioned 
suppuration  and  peritonitis  by  inoculation  of  erysipelas  cul- 
tures.   Nor  were  the  results  confined  to  one  species  of  animal. 

Prof.  William  H.  Welch,  Johns  Hopkins  University,  Balti- 
more, in  his  reply  to  a  recent  communication  from  me  request- 
ing his  opinion,  says:  "Streptococcus  erysipelatis  (Fehleisen) 
cannot  be  distingushed  by  any  properties  morphologic,  cul- 
tural, pathogenic,  from  streptococcus  pyogenes,  and  prac- 
tically all  authorities  in  bacteriology  consider  the  two  identical. 
Attempts  to  subdivide  into  different  species  or  varieties  the 
various  streptococci  found  in  human  beings  in  health  and  in 
disease,  have  met  with  little  success.  There  is  a  wide  range 
of  variation,  of  course,  in  all  properties,  but  none  seem  suf- 
ficiently constant  to  serve  as  a  basis  of  classification.  We 
must,  I  think,  recognize  that  a  given  streptococcus,  at  least 
for  the  time  being,  is  endowed  with  certain  biologic  quali- 
ties which  render  it  capable  of  producing  effects  which  an- 
other streptococcus  may  not  be  able  to  produce,  but  such  bio- 
logic differences  are  either  too  inconstant  or  beyond  our 
control  or  methods  of  study  to  enable  us  to  base  species  charac- 
ters upon  them." 

Having  determined  the  status  of  the  infectious  organism, 
let  us  inquire  as  to  its  normal  habitat  and  the  probable  circum- 
stances under  which  it  invades  and  produces  disease  in  the 
tissues  of  the  body  of  man. 

We  know  the  normal  habitat  of  the  typhoid  bacillus  and 
the  means  by  which  it  gains  access  to  the  body;  we  know  the 
normal  habitat  of  the  bacillus  of  tetanus  and  how  it  gains 
entrance  to  its  unwilling  human  host,  and  we  are  now  in  a 
position  to  declare  that  we  know  the  normal  habitat  of  the 
streptococcus  and  how,  under  certain  circumstances,  it  can 
virulently  attack  and  produce  disease  in  man. 

The  nose,  the  antra  of  Highmore,  the  ethmoid  cells,  the 
sphenoid  cell  or  cells,  the  frontal  sinus  or  sinuses,  the  Eu- 
stachian tube,  the  middle  ear  and  the  mastoid  antrum,  present 
a  continuous  surface  of  mucous  membrane  of  fairly  identical 


6  ETiOIvOGY  OF  ERYSIPELAS. 

Structure  in  all  its  parts,  moistened  physiologically  by  a  more 
or  less  abundant  mucous  secretion  and  directly  continuous  by 
way  of  the  nasopharynx  with  the  pharynx,  the  tonsillar  region 
and  the  mouth. 

Lewis  and  Turner  (50),  of  Edinburgh,  published  in  1905 
a  bacteriologic  study  of  the  nose  and  its  accessory  cavities 
and  I  have  availed  myself  freely  of  their  work  for  the  reason 
that  they  have  reviewed  all  of  the  previous  literature  and  have, 
by  their  own  labors,  practically  brought  the  subject  down  to 
date. 

Thompson  and  Hewlett  (36)  in  .1895  had  examined 
ninety-one  cover  glass  smears  from  nasal  mucus  and  nasal 
mucous  membrane  and  had  found  eighty  per  cent  of  those 
from  the  interior  of  the  nose  sterile.  The  vestibule  was  never 
sterile. 

-  The  work  of  subsequent  observers,  however,  cast  doubt  upon 
these  results.  Klemperer,  and  Park  and  Wright  (37)  deter- 
mined that  the  interior  of  the  healthy  nose  is  not  free  from 
germs  and  that  the  nasal  secretion  has  no  bactericidal  action. 
They  found  only  six  cases  sterile  out  of  thirty-six  specimens 
taken.  Hasslauer  (38)  in  an  examination  of  186  specimens 
from  111  nasal  cavities  found  the  Staphylococcus  pyogenes 
albus  in  twenty-five  per  cent,  the  pneumococcus  in  20  per 
cent,  the  streptococcus  pyogenes  in  seventeen  per  cent,  and  the 
pseudo-diphtheria  bacillus  in  thirteen  per  cent.  Viollet  (39) 
also  found  staphylococci,  streptococci  and  ipneumococci  in 
normal  nasal  secretion.  Finally  Lewis  and  Turner  endeavored 
to  eliminate  the  sources  of  error  encountered  by  their  prede- 
cessors and  undertook  and  published  this  most  valuable  and 
conclusive  series  of  observations  on  the  healthy  and  the  in- 
flamed nose,  mouth  and  accessory  nasal  cavities. 

They  took  twenty-six  specimens  from  sixteen  healthy  noses, 
and  of  these  only  three  were  found  sterile.  Thirteen  specimens 
from  seven  persons  were  mono-organismal.  Nine  from  seven 
persons  showed  two  varieties  of  bacteria.  One  specimen 
showed  three  varieties.  The  pneumococcus  was  found  in  four 
cases,  staphylococci  in  thirteen,  streptococci  in  six,  Hoffman's 
bacillus  in  two,  bacillus  aureus  in  two,  bacillus  mesentericus 
in  two,  spirillum  in  two,  bacillus  of  Friedlander,  the  proteus 
vulgaris  and  unknown  bacillus  in  one  each.  Organisms  from  nine 
healthy  noses  were  non-pathogenic  on  inoculation  in  animals. 
From  two  healthy  noses  pathogenic  organisms  were  obtained. 


ETIOLOGY  OF  ERYSIPEIvAS.  7 

From  one  of  these  the  staphylococcus  aureus  and  albus,  pro- 
duced local  abscess  in  but  were  not  fatal  to  guinea  pigs.  In 
the  other  case  streptococcus  pyogenes  was  present,  the  broth 
culture  proving  fatal  to  a  rabbit  in  fourteen  days  after  intra- 
peritoneal injection  of  2  c.  c  Slow  growth  on  culture  media 
makes  it  appear  "that  the  interior  of  the  normal  nose  may 
appear  sterile,  owing  to  the  fact  that  organisms,  though  pres- 
ent, occur  in  such  few  numbers  as  to  escape  recognition  by 
rapid  methods.  Further  it  appears  that  the  staphylococci  found 
in  the  healthy  nose  are  often  of  low  vitality  and  do  not  grow 
so  readily  in  ordinary  media  as  the  same  varieties  derived  from 

pus It  happened  more  than  once  that  broth  in 

which  a  swab  had  been  immersed  and  incubated  for  forty- 
eight  hours  showed  no  cloudiness  or  other  sign  of  growth  in 
the  first  twenty- four  hours ;  on  the  second  day,  however,  the 
broth  either  became  cloudy  throughout  or  remained  clear,  but 

with  distinct  sedimentary  growth The  inference 

is  that  the  nose  contained  numerically  few  organisms  or  that 
the  organisms  present  in  the  nose  were  of  diminished  vigor 
and  were  revived  after  a  period  in  a  suitable  medium,  such  as 
broth." 

It  appears  that  the  organisms  of  the  healthy  nose  belong 
to  the  same  varieties  as  those  found  in  abnormal  conditions, 
but  that  they  differ  from  the  flora  of  pathologic  nasal  mem- 
brane in  actual  numbers,  in  purity  of  culture,  in  vigor  of 
growth  and  in  pathogenicity. 

In  inflammatory  conditions  of  the  nasal  cavities,  the  organ- 
isms present  belong  to  very  much  the  same  varieties  as  those 

which  may  be  found  in  the  healthy  cavities All 

the  varieties  present  may  not  be  pathogenic  on  injection  into 
animals,  but  usually  one  variety  is  virulent  in  the  early  stages 

of  the  disease The  pathogenicity  is  high  at  first 

and  diminishes  rapidly  so  that  an  organism  isolated  in  the 
first  few  days  of  a  nasal  catarrh  and  then  very  fatal  to  guinea 
pigs,  becomes   later   incapable   of   producing  any   pathogenic 

effect To  produce  nasal  inflammation  not  only 

is  the  presence  of  pathogenic  varieties  necessary,  but  these 
varieties  must  be  virulent,  or  if  avirulent,  must  recover  their 
virulence  by  the  influence  of  other  factors. 

Thirteen  specimens  were  examined  from  eight  acute  cases 
and  one  chronic  case  of  purulent  nasal  catarrh. 

The  streptococcus  pyogenes  was  present  in  six  of  the  acute 


8  ETIOLOGY  OF  ERYSIPEIvAS. 

and  in  the  chronic  case — various  staphylococci  were  present  in 

six  cases  and  the  pneumococcus  in  one  case.  Of  the  eight  acute 
eases,  pure  cultures  of  staphylococci  were  obtained  in  two  and 
in  the  remaining  six  the  streptococcus  was  the  probable  excit- 
ing cause. 

In  the  chronic  case,  both  were  found,  but  the  streptococcus 
was  probably  the  etiologic  factor.  From  three  of  the  cases 
virulent  pathogenic  organisms  were  obtained — twice  the  strep- 
tococcus and  once  the  staphylococcus  pyogenes  citreus.  The 
streptococci  in  these  cases  were  so  virulent  as  to  prove  fatal  to 
guinea  pigs  in  twenty-four  hours.  Ten  days  later  the  strepto- 
coccus isolated  afresh  from  the  discharge  in  one  of  these  cases 
proved  nonpathogenic. 

The  pathogenic  bacteria  of  the  mouth  include  many  varieties 
which  are  found  in  suppuration  of  the  antrum  and  other 
sinuses.  The  streptococcus  pyogenes,  the  staphylococci,  the 
pneumococcus,  the  B.  diphtheriae  and  the  B.  pyocyaneus  are 
all  found  at  times  in  the  mouth.  In  addition  to  the  organisms 
specially  associated  with  carious  teeth — streptococcus  brevis, 
B.  necrodentalis  and  staphylococcus  albus — any  of  the  denizens 
of  the  mouth  may,  of  course,  be  found  on  the  outer  surfaces, 
if  not  in  the  deeper  layers  of  the  carious  matter. 

Torne  (44)  has  published  the  only  observations  on  the  bac- 
teria of  the  healthy  accessory  sinuses.  He  examined  thirty- 
six  cadavera  in  which  the  maxillary  and  frontal  sinuses  were 
healthy.  Twenty-two  were  examined  within  two  an.d  one-half 
hours  after  death  and  in  all  these  the  sinuses  were  found  ster- 
ile. Of  the  remaining  fourteen  examined,  from  three  to 
twenty-five  hours  post  mortem,  seven  were  sterile  and  seven 
contained  bacteria.  This  suggests  that  the  entrance  of  organ- 
isms occurs  some  hours  after  death. 

The  maxillary  and  frontal  sinuses  were  sterile  in  twenty- 
nine  of  the  thirty-six  cadavera  examined  within  twenty-five 
hours  post  mortem.  Torne  also  examined  twenty-six  pathologic 
cavities  in  sixteen  cadavera.  Eleven  cavities  examined 
three  hours  post  mortem  showed  catarrhal  changes,  but  nine 
of  these  were  sterile.  Twelve  cavities  showed  chronic  puru- 
lent inflammation.  There  were  present  streptococci,  micro- 
coccus pyogenes  aureus,  pseudo-catarrhalis,  tardiliquans,  etc. 
Three  cavities  in  acute  cases  examined  one  and  one-fourth 
hours  after  death,  all  showed  bacillus  pneumoniae. 

Pearce   (45)   found  inflammatory  changes  in  the  maxillary 


ETIOLOGY  OF  ERYSIPELAS.  9 

antrum  of  many  cases  of  diphtheria,  with  Klebs-Loeffler  bacilli 
present  in  nearly  all. 

In  four  cases  of  diphtheria,  complicated  with  scarlet  fever, 
pus  was  found  in  the  antra  in  three  and  the  organisms  present 
were  streptococci  and  staphylococci.  In  102  post  mortem 
examinations  in  which  the  accessory  sinuses  were  examined, 
Kirkland  and  Stacey  (46)  found  thirty- four  cases  of  infection 
by  microorganisms  in  which  streptococci,  staphylococci  and 
pneumococci  were  found. 

Herzfeld  and  Herman  (47)  in  ten  cases  of  antral  suppura- 
tion found  the  streptococcus  in  eight  cases  and  staphylococcus 
in  seven. 

Howard  and  Ingersoll  (48),  in  an  investigation  as  to  the 
causes  of  inflammations  of  the  accessory  sinuses,  concluded  that 
these  inflammations  are  due  to  the  bacteria  which  are  commonly 
present  in  the  buccal  and  nasal  cavities — in  the  former  in  health 
and  in  the  latter  occasionally  in  health  and  usually  in  disease. 
These  organisms  are  the  diplococcus  lanceolatus,  streptococcus, 
staphylococcus  pyogenes,  B.  diphtheriae  and  B.  influenzae. 

Stanculeanu  and  Baup  (49)  determined  that,  clinically  and 
bacteriologically,  there  are  two  varieties  of  empyema  of  the 
facial  sinuses,  one  with  fetid  pus  following  on  dental  affections 
(14)  and  the  other  of  nasal  origin  with  non-fetid  pus — the 
latter  being  due  to  such  organisms  as  the  streptococcus  and 
the  pneumococcus.  The  greater  frequency  of  anaerobic  or- 
ganisms in  the  mouth  lends  some  support  to  these  views.  As 
to  pathogenicity,  they  state  that  in  cases  of  nasal  origin  the 
aerobes,  and  in  cases  of  dental  origin  the  anaerobes,  are  always 
found  virulent  on  injection  into  animals. 

Finally,  Lewis  and  Turner  themselves  report  on  their  ex- 
tensive series  of  observations.  They  examined  eighty  speci- 
mens of  pus  from  fifty-seven  antral  cavities.  They  found 
streptococci  in  43  or  75.4  per  cent,  pneumococci  in  42  or  74.1 
per  cent,  and  staphylococci  in  40  or  70.1  per  cent.  Swabs  were 
taken  from  the  nasal  chambers  of  forty-two  of  these  cases. 
Pneumococci  were  found  in  twenty-nine,  or  70  per  cent,  staphy- 
lococci in  twenty-eight,  or  66.6  per  cent  and  streptococci  in 
twenty-seven,  or  64.3  per  cent.  Swabs  were  taken  directly 
from  the  antral  cavities  in  twenty-seven  of  the  cases.  Pneu- 
mococci were  found  in  twenty-one,  or  77  per  cent,  staphy- 
lococci in  twenty-one,  or  77  per  cent,  and  streptococci  in  twenty- 
one,  or  77  per  cent.     Of  the  forty-seven  cavities,  there  were 


10  ETIOI^OGY   OF  ERYSIPELAS. 

only  four  in  which  the  swab  yielded  an  absolutely  pure  culture. 
In  two,  the  streptococcus,  in  one  the  staphylococcus,  and  in 
one  the  pneumococcus. 

Thirteen  acute  cases  showed  staphylococci  in  eleven,  or  84.6 
per  cent;  pneumococci  in  eleven  or  84.6  per  cent,  and  strepto- 
cocci in  eight,  or  61.6  per  cent.  Forty- four  chronic  cases 
showed  streptococci  in  thirty-five,  or  80  per  cent ;  pneumococci 
in  thirt3-one,  or  70  per  cent,  and  staphylococci  in  twenty-nine, 
or  66  per  cent.  The  B.  influenza,  which  was  only  obtained  in 
one  instance,  occurred  in  a  recent  case  of  only  three  weeks' 
duration. 

The  authors  state :  "Though  in  the  wealth  of  organisms 
associated  in  these  cases,  and  possibly  pathogenic,  it  could  not 
be  certainly  stated  which  was  the  fons  et  origo  mali,  yet  in 
some  of  the  cases  we  were  enabled  to  conjecture  which  organ- 
ism was  most  probably  responsible.  This  we  did  on  considera- 
tion (1)  of  the  pathogenicity  of  the  organism  (as  ascertained 
by  experiments  on  animals)  and  (2)  of  the  organisms  in  direct 
swab  as  compared  with  nasal  swab  from  the  same  case,  and 
(3)  of  the  persistence  in  chronic  cases  of  particular  varieties, 
and  (4)  of  the  occurrence  in  pure  culture  of  one  organism. 
In  this  way  we  are  able,  though  with  some  diffidence,  to  assign 
the  principal  role  to  the  pneumococcus  in  fourteen,  to  the 
streptococcus  pyogenes  in  nineteen  and  to  the  staphylococcus 
in  six  of  the  fifty-seven  cavities." 

Among  the  recent  cases,  the  pneumococcus  was  probably 
responsible  for  the  inflammation  in  four,  the  staphylococcus  in 
three,  and  the  streptococcus  in  two — four  cases  being  undeter- 
minable. Among  the  long-standing  cases,  the  pneumococcus 
was  probably  responsible  in  ten,  the  staphylococcus  in  three 
and  the  streptococcus  in  seventeen — fourteen  being  undeter- 
minable. 

In  twelve  cases,  the  antral  disease  was  complicated  by  in- 
flammation of  the  ethmoid  in  four  cases,  by  disease  of  the 
frontal  sinuses  in  six  cases,  and  by  disease  of  both  ethmoid 
and  frontal  in  two  cases.  Ten  cavities  showed  staphylococci, 
seven  showed  streptococci  and  seven  pneumococci.  Pus  from  a 
chronic  inflammation  of  the  ethmoid  sinus  alone  showed  both 
streptococci  and  staphylococci.  Pus  from  the  frontal  sinus 
alone  showed  in  one  case  pneumococcus  and  staphylococcus, 
and  in  another  case  streptococcus  and  staphylococcus,  and  in  a 
third  case  all  three  orgajiisms. 


ETIOLOGY  OF  ERYSIPEI.AS.  11 

In  order  to  ascertain  whether  the  combinations  of  organ- 
isms present  might  be  pathogenic,  even  though  the  individual 
organisms  in  pure  culture  were  not  so,  several  injections  of 
impure  cultures  were  made.  The  results  yielded  no  evidence 
that  organisms,  which  in  pure  culture  were  non-pathogenic, 
would  in  combination  give  rise  to  disease.  The  reverse  was, 
however,  not  the  case,  for  in  three  instances  a  pneumococcus, 
which  in  pure  culture  was  pathogenic,  produced  no  illness 
when  injected  along  with  the  other  organisms  present  in  the 
same  case.  Pneumococci,  tested  in  ten  acute  cases,  were 
pathogenic  to  irabbits  in  five,  or  50  per  cent.  Staphylococci, 
tested  in  ten  acute  cases,  were  pathogenic  to  guinea  pigs  in 
five,  or  50  per  cent,  and  streptococci,  tested  in  eight  acute 
cases,  were  pathogenic  in  six,  or  75  per  cent. 

Pneumococci,  tested  in  seventeen  chronic  cases,  were  patho- 
genic to  rabbits  in  five,  or  29  per  cent.  Staphylococci,  tested 
in  twenty-eight  chronic  cases,  were  pathogenic  in  nine,  or  33 
per  cent.  In  four  cases  in  which  the  condition  had  lasted  more 
than  eight  years,  streptococci  were  found  pathogenic  to  ani- 
mals, but  not  fatal. 

"In  'recent  cases  the  organisms  are  pathogenic  twice  as  often 
as  in  chronic  cases."  "In  both  recent  and  chronic  cases,  the 
streptococci  are  more  pathogenic  to  animals  than  all  other 
varieties."  "The  streptococci  are  almost  always  pathogenic 
when  recovered  from  recent  cases,  but  in  chronic  cases  seem 
to  have  largely  lost  their  virulent  characters.  There  is  no  guar- 
antee, however,  that  these  organisms  would  remain  so  little 
virulent  if  by  chance  implanted  on  more  suitable  soil." 

Iglauer  (73)  of  Cincinnati,  working  in  the  Pathological  In- 
stitute of  Vienna,  and  taking  nasal  mucus  directly  from  the 
posterior  nares  by  means  of  a  head  section  as  soon  post  mortem 
as  practicable,  found,  in  twenty  selected  cases,  the  staphylo- 
coccus pyogenes  aureus  in  eleven  cases,  the  staphylococcus  pyo- 
genes albus  in  six  cases,  the  diplococcus  pneumoniae  in  eight 
cases  and  the  streptococcus  pyogenes  in  six  cases.  In  fourteen 
additional  cases  in  which  there  was  a  marked  pulmonic  lesion, 
he  found  the  staphylococcus  pyogenes  aureus  in  seven  cases, 
the  staphylococcus  pyogenes  albus  in  eight  cases,  the  diplo- 
coccus pneumoniae  in  eight  cases  and  the  streptococcus  in  six 
cases.  Finally,  as  a  negative  contribution  to  the  etiology  of 
diseases  of  the  maxillary  antrum,  the  only  one  of  the  accessory 
cavities  suspected  of  having  any  other  than  a  nasal  source  for 


12  ETIOLOGY  OF  ERYSIPELAS. 

the  inflammations  that  attack  it,  I  would  quote  Fletcher  (70), 
who  examined  the  200  antra  of  100  skulls  for  (1)  abscessed 
teeth,  (2)  septa,  (3)  for  conical  protrusions  of  the  roots  of 
the  teeth  into  the  antrum,  (4)  for  perforation  by  the  roots  of 
the  teeth  without  protrusion  and  (5)  for  perforation  of  the 
antrum  from  ulcerated  teeth.  He  says:  "As  to  the  molars, 
ulceration  was  found  in  more  than  25  per  cent  of  the  skulls, 
there  being  in  these  200  examinations  fifty-seven  ulcerated 
teeth,  and  out  of  these  fifty-seven  possible  cases  of  perforation 
by  inflammation  and  its  results,  we  found  such  to  be  the  case 
only  four  times,  all  other  cases  having  perforated  the  alveolar 
border  and  discharged  the  pus  into  the  mouth,  two  of  them 
discharging  both  in  the  mouth  and  in  the  antrum."  Lewis 
and  Turner  cite  a  number  of  observers  to  the  same  effect. 

It  is  quite  possible  for  bacteria  to  enter  the  middle  ear  and 
they  probably  do  so,  through  the  Eustachian  tube,  remaining 
dormant  under  normal  conditions  and  eventually  losing  their 
vitality.  In  scarlet  fever  and  other  severe  anginas,  the  micro- 
organisms effect  an  indirect  invasion  by  way  of  the  lymphatics 
— and  in  other  diseases,  such  as  endocarditis  and  diphtheria, 
by  way  of  the  blood  vessels.  Politzer  (74)  says  that  entrance 
may  be  effected  from  the  external  auditory  canal  through  either 
the  perforated  or  intact  membrana  tympani.  Zaufal  and  Nado- 
leczny,  quoted  by  Politzer,  state  that  the  streptococcus  pyog- 
enes and  diplococcus  pneumoniae  are  the  exciting  causes  of 
acute  otitis  media.  If  the  middle  ear  secretion  is  examined 
immediately  after  a  paracentesis  diplococci  and  streptococci 
occur  just  as  often  alone  as  in  combination  with  other  patho- 
genic micro-organisms.  Except  in  the  case  of  such  specific 
diseases  as  diphtheria,  typhoid,  influenza  and  epidemic  cerebro- 
spinal meningitis,  where  the  specific  micro-organisms  of  these 
diseases  are  found,  the  finding  of  micro-organisms  in  the  dis- 
charge other  than  the  pneumococcus  or  the  streptococcus  indi- 
cated a  secondary  infection. 

Lermoyez  and  Helme  (82)  came  to  the  conclusion  from  in- 
numerable investigations  that  otitis  media  acuta  is  always  of 
mono-bacilHc  origin  and  that  the  pneumococcus  or  streptococ- 
cus is  seldom  found  in  combination  with  other  organisms.  Sec- 
ondary infection  by  the  staphylococcus  takes  place  only  in  the 
later  course  of  the  disease,  per  tubam  or  through  the  external 
auditory  canal. 

Before    quitting    the    subject    of    the    bacteriology    of   the 


ETIOLOGY   OF   ERYSIPELAS.      "  13 

nose,   the   sinuses   and   the    ear,    I    wish    to    call   your    atten- 
tion   to    two    significant    observations.     One    was    made    by 
Dench  and  Cunningham  (75)  and  reported  to  the  American 
Otological  Society  in  1902  in  a  paper  on  "The  Value  of  Bac- 
teriological  Examination   of  the   Discharge   in   Acute    Otitis 
Media  as  '^Determining  the  Necessity  of  Operative  Interfer- 
ence."   They  say :    "The  presence  of  the  pneumococcus  as  the 
sole  etiologic  factor  signifies  a  rather  mild  form  of  inflamma- 
tion in  the  mastoid  cells.     ...     On  the  other  hand,  it  has 
been  most  interesting  to  note  the  rapidity  with  which   the 
streptococcus  infection  develops.     .     .      .     The  osseous  struc- 
tures have  been  found  at  the  time  of  operation  to  be  extensively 
involved,  even  in  those  cases  which  have  been  operated  upon 
in  the  very  earliest  stages  of  the  disease.    In  many  cases  in 
which  the  inflammatory  process  had  existed  but  from  forty- 
eight  to  seventy-two  hours,  extensive  destruction  of  the  bone 
had  taken  place."     In  four  recent  cases  of  streptococcus  in- 
fection which  had  apparently  cleared  up,  the  patients  returned 
complaining  of  a  recurrence  of  the  local  pain  with  a  slight 
discharge  from  the  ear  and  an  appearance  of  general  sepsis 
and  in  these  cases,  upon  operation,  a  most  extensive  destruc- 
tion of  the  bony  tissue  was  found.     In  three  cases  epidural 
abscess  had  been  present  and  in  a  fourth  case  thrombosis  of 
the  lateral  sinus  existed  at  the  time  of  operation. 

The   following  tables,   which   require   no  explanation,   are 
given : 

Nature  of  Infection    No.  Cases     Ice  Coil     Operation    No  Operation 
Streptococcus  (pure).        33  17  2  8  5 

Staphylococcus 3  3  2  1 

Pneumococcus 21  21  2  19 

Mixed   infection  "witli 
streptococus  pres- 
ent          25  19  23  2 

Mixed  infection  with 
no  streptococcus 
present 9  9  3  6 

Recovery. 

Ice  Coil.  Operation. 

Streptococcus ,  14%  86% 

Staphylococcus 33  1/3%  66  2/3% 

Pneumococcus 90%  10% 

Mixed  with  streptococcus 8%  92% 

Mixed   no   streptococcus 66    2/3%  33    1/3% 


14  ETIOLOGY   OF   ERYSIPELAS. 

The  other  significant  observation  is  from  the  pathologic 
laboratory  of  the  Ancon  Hospital,  Isthmus  of  Panama.  Dar- 
ling (56)  writes:  "This  communication  contains  some  of  the 
results  of  an  investigation  which  is  being  conducted  to  deter- 
mine the  relation  of  inflammation  of  the  accessory  nasal  sinuses 
to  pneumococcus  infections.  .  .  .  The  accessory  sinuses 
have  been  examined  with  regard  to  this  point  in  fifty-two  au- 
topsies, twenty-seven  of  which  were  pneumococcus  infections, 
as  follows :  Lobar  pneumonia,  22 ;  acute  pericarditis,  1 ;  acute 
meningitis,  9;  pneumococcus  septicemia,  5.  The  remaining 
cases  were  controls. 

It  has  been  found  that  92  per  cent  of  all  penumococcus  in- 
fections coming  to  autopsy  show  in  a  very  marked  degree  more 
or  less  typical  pneumococcus  inflammation  of  one  or  more  of 
the  accessory  nasal  sinuses.  The  inflammation  is  generally  in- 
tense. It  is  fibrinopurulent  in  character — fibrin  and  mononuclear 
cells  being  abundant.  Pneumococci  are  always  present  and  in 
numbers  depending  on  the  duration  of  the  process.  A  point  of 
great  importance  is  the  age  of  the  sinus  affection,  which  has 
been  appreciably  greater  than  that  of  the  lung  or  meningeal 
lesion.  Ninety-one  per  cent  of  the  lobar  pneumonia  cases 
showed  a  sinusitis.  All  cases  of  acute  pneumococcus  menin- 
gitis presented  an  inflammation  of  one  or  more  of  the  sinuses 
and  in  every  one  the  middle  ears  and  mastoid  cells  were  normal. 
In  the  pneumococcus  septicemia  group,  80  per  cent  were  found 
to  be  associated  with  a  sinusitis." 

Is  it  not  possible  for  us  now  to  assign  their  proper  pathogenic 
role  to  the  two  principal  pathogenic  bacteria  which  have  their 
normal  habitat  in  the  nose  and  its  accessory  sinuses — the  pneu- 
mococcus producing  such  a  disease  as  lobar  pneumonia,  acute 
purulent  cerebro-spinal  meningitis  (pneumococcus),  endocar- 
ditis, pericarditis  and  mild  infections  of  the  middle  ear — while 
the  streptococcus  produces — starting,  as  it  does,  from  the  same 
base — violent  inflammations  of  the  ear — purulent  meningitis, 
cerebral  abscess,  metastatic  abscesses  of  various  kinds,  and,  as 
I  shall  now  proceed  to  show,  erysipelas. 

As  is  almost  invariably  the  case  with  any  material  advance 
in  our  knowledge  of  the  physical  and  biologic  sciences,  it 
happens  that  a  number  of  pathologists  in  different  countries 
have  made  approximately  the  same  suggestion,  at  about  the 
same  time,  but  either  because  their  theories  were  advanced 
through  some  medium  that  had  but  a  limited  circulation  in  a 
language  not  generally  read,  or  because  their  papers  did  not  fall 


.     ETIOLOGY   OF   ERYSIPELAS.  15 

under  the  notice  of  systematic  students  of  and  writers  upon 
pathology,  or  because  the  amount  of  evidence  they  could  pro- 
duce at  the  time  was  not  sufficiently  convincing — it  is  that  up  to 
the  present  their  work  has  attracted  but  little  if  any  attention. 
H.  M.  Fish  quotes  Ribed  as  having  in  1845,  traced  two  cases 
of  orbital  abscess  to  a  sinusitis,  and  as  having  said :  "Intraorbital 
abscesses,  observed  at  times  after  facial  erysipelas,  are  not  the 
result  of  the  erysipelas,  but,  on  the  contrary,  they  are  the 
cause  or  place  of  departure" — and  quotes  Zucarini  as  saying 
in  1853 — "The  increased  secretion  of  mucus  within  the  sinuses, 
when  drainage  is  insufficient,  soon  changes  to  a  mucopurulent 
form;  its  resorption  induces  erysipelas,  and  the  appearance, 
increase  and  subsidence  of  the  erysipelas  depends  entirely  upon 
a  successful  drainage  of  the  cavities."  In  1891  Luc  (14)  re- 
ported the  following  significant  case — '"Following  upon  an 
erysipelas  of  the  face  which  had  already  manifested  its  sup- 
purative tendency  by  occasioning,  in  the  course  of  its  evolu- 
tion, an  abscess  of  the  Hd,  the  symptoms  of  an  empyema  of 
the  left  antrum  of  Highmore  appeared.  Only  after  9  months 
was  this  empyema  recognized  and  operated  upon  and  an 
examination  of  the  pus  revealed  the  exclusive  presence  of  the 
chains  of  streptococci  characteristic  of  erysipelas  .... 
Some  days  after  the  double  operation  (removal  of  polypous 
masses  from  the  middle  meatus  and  opening  the  antrum  from 
the  mouth)  and  without  having  been,  at  least  apparently,  sub- 
mitted to  any  contagious  influence,  but  after  several  excursions 
through  intense  cold,  the  patient  was  attacked  by  a  facial  ery- 
sipelas which  began  at  the  left  nostril."  Previous  to  seeing 
this  case  Luc  believed  that  all  empyemata  of  the  antrum  of 
Highmore  were  of  dental  origin.  His  earlier  cases  he  believed 
could  all  be  traced  to  dental  caries ;  the  pus  from  the  cavities 
contained  many  varieties  of  organisms  and  it  was  invariably 
fetid.  In  this  erysipelatous  case,  however,  Dr.  Ledoux  Le- 
bard  found  streptococci  in  pure  culture  in  the  antrum  (the 
teeth  of  the  patient  were  sound)  while  in  another  antral  case 
operated  upon  at  the  same  time  by  Luc,  the  origin  of  which 
was  undoubtedly  dental  and  in  which  the  pus  was  malodorous, 
Lebard  found  staphylococci,  diplococci,  long  filaments  of 
short,  round,  oval  or  rod-like  segments  and  isolated  bacilli  and 
micrococci.  In  1896  a  Swedish  author,  C.  Janson  (51),  in  a 
remarkable  article  on  "Causes  of  Infection  in  Facial  Ery- 
sipelas"     (Forhandlingar   vid    Forsta    Nord^'ska   Kongressen, 


16  ETIOLOGY  OF  ERYSIPELAS. 

August,  1896),  first  formulated  the  correct  theory  of  the  etiol- 
ogy of  the  disease  without,  however,  adducing  any  cases  in 
proof  of  his  contention,  which  may  be  the  reason  why  the 
paper  has  attracted  so  little  attention.  I  translate  a  few  para- 
graphs as  follows :  "It  must  strike  one  as  remarkable  that 
facial  erysipelas  is  so  much  more  frequent  than  all  other  forms 
of  erysipelas.  The  constant  exposure  of  the  face  cannot  be 
the  only  'reason,  because  the  hands  are  equally  exposed  and 
much  more  frequently  come  in  direct  contact  with  substances 
that  might  cause  infection — yet  erysipelas  of  the  hands  is 
relatively  a  rare  occurrence.  Facial  erysipelas  generally  be- 
gins at  the  nose,  and  fissures  at  the  entrance  of  the  nares  have 
long  been  regarded  as  the  points  of  entrance  of  the  infection. 
Two  symptoms  are  found  in  this  disease  that  are  frequently 
overlooked  although  they  very  often  usher  in  the  erysipelas — 
viz.,  nasal  catarrh  and  inflammations  of  the  pharynx.  When 
we  consider  this  it  is  rational  to  assume  that  the  cause  of  the 
infection  in  erysipelas  has  its  origin  in  the  nose  and  pharynx. 

It  has  been  demonstrated  that  streptococci  can  always  be 
found  in  the  pharynx  of  a  healthy  person,  and  they  could — • 
even  if  under  ordinary  conditions  they  are  non-virulent — as- 
sume  an   activity  that   would   develop   erysipelas   or   a   fatal 

septicemia The  author  believes  that  in  general 

the  streptococci,  which  are  harmless  saprophytes  in  the  pharynx 
under  certain  as  yet  not  well  understood  conditions,  can  cause 
facial  erysipelas  with  or  without  angina  or  coryza  as  a  pri- 
mary cause  and  that  the  infection  usually  develops  in  this 
manner.  Streptococci  then  come  to  belong  to  the  same  group 
as  the  pneumococci  and  colon  bacilli — viz.,  saprophytes  with 
faculative  virulence." 

Six  months  later  Mermet  (11)  in  discussing  palpebral  ery- 
sipelas brought  forward  considerations  of  almost  equal  theoret- 
ical significance.  He  pointed  out  "that  the  streptococcus  is 
not  an  habitual  inhabitant  of  the  skin,  that  we  have  not  been 
able  to  find  it  on  the  norrrtal  lids  and  that  Achalme  has  not 
been  able  to  obtain  cultures  exposed  freely  to  the  air  even  in 
wards  affected  with  erysipelas — note  finally  that  the  absence 
of  predisposition  of  this  affection  for  the  lids  of  the  right 
side  seems  to  preclude  the  idea  of  a  contamination  by  the 
hands  of  the  patient Very  frequently  the  strepto- 
coccus infection  of  the  lids  is  secondary  either  to  an  external 
erysipelas  or  to  an  affection  of  the  lachrymal  sac  and  canal. 


rCTIOLOGY   OF   ERYSIPELAS.  17 

of  the  conjunctiva  or  of  the  cavities  of  the  face 

We  should  point  out  here  a  fact  of  the  greatest  importance :  it 
is  the  predilection  that  the  streptococcus  has  to  travel  by  way 
of  the  lymphatics  and  the  subcutaneous  tissue,  evincing  a  pref- 
erence for  the  ascending  channels  of  the  mucous  membranes. 
This  observation  accounts  to  us  for  the  predominance  of 
streptococcic  lid  lesions  considering  the  conjunctival  determina- 
tions in  the  cases  of  palpebral  erysipelas  consecutive  to  in- 
fections of  the  sac  or  the  upper  lachrymal  canal."  In  discussing 
recurrent  erysipelas  Mermet  observes  "one  can  very  easily 
conceive  that  the  streptococci,  which  normally  inhabit  the 
mouth,  the  nasal  fossae  and  the  lachrymal  ducts  in  the  quality 
of  inoffensive  guests  recover  their  virulence  under  some  in- 
fluences analogous  to  those  which  experimentation  has  real- 
ized and  invade  the  lids." 

•  H.  Roger  (69)  also,  after  a  personal  study  of  957  cases 
says : — "Classic  authors  consider  an  erysipelatous  angina  as 
very  frequent ;  our  observations  on  this  point  do  not  accord 
with  this  opinion.  Very  often,  it  is  true,  the  patients  com- 
plain of  having  suffered  with  sore  throat,  but  the  objective 
examination  was  entirely  negative  and  a  close  inquiry  indi- 
cated to  us  that  it  was  a  matter  in  reality  of  painful  swelling 
of  the  cervical  glands.  Adenitis  frequently  accompanies  ery- 
sipelas. In  21  cases  it  has  preceded  by  at  least  one  day  the 
cutaneous  eruption.  The  nasal  fossae,  we  believe,  ought  to 
be  suspected  more  often  than  the  pharynx;  in  many  cases  the 
patients  were  suffering  with  coryza  for  a  greater  or  less  time 
and  the  infection  seems  to  have  invaded  the  skin  by  way  of 
an  ulceration  of  the  mucous  membrane  at  the  nasal  vestibule." 
He  refers  also  to  the  fact  that  streptococci  spread  anteriorly 
upon  the  skin  may  penetrate  the  cutaneous  glands  and  there 
develop  into  inflammatory  activity  upon  the  occasion  of  an 
intercurrent  cause  such  as  a  chill.  A.  Logan  Turner  also  adds 
a  definite  expression  of  opinion  in  his  recent  work  on  The 
Accessory  Sinuses  of  the  Nose.  He  says:  "Suppuration  has 
been  ascribed  by  Weichselbaum  to  an  attack  of  facial  ery- 
sipelas ;  it  is  more  reasonable  when  these  conditions  are  as- 
sociated to  regard  the  erysipelas  as  secondary  to  the  nasal 
discharge." 

The  French  authors  and  teachers  seem  to  have  appreciated 
the  causal  conditions  of  facial  erysipelas  for  a  number  of 
years   past.     Thus   we   find   in   a  thesis   for  the   doctorate   at 


18  ETIOLOGY   OF   ERYSIPELAS. 

Bordeaux  by  Fauveau  the  following  most  excellent  description : 
"In  medical  erysipelas"  (spontaneous,  idiopathic)  "the  port 
of  entry  of  the  contagion  frequently  passes  unperceived,  when 
the  site  of  the  disease  is  the  face,  because  it  is  hidden  in  the 
natural  cavities  such  as  the  mouth,  the  pharynx,  the  external 

auditory  canal  or  the  nasal  fossae It  is  frequently 

by  way  of  the  nasal  mucous  membrane  that  the  facial  erysipelas 
that  is  cahed  spontaneous  or  recurrent  erysipelas  arises.  The 
pharynx  is  also  one  of  the  seats  of  predilection  of  erysipelas 
of  the  mucous  membranes.  From  there  it  extends  itself  easily, 
thanks  to  the  laxity  of  the  tissues  of  this  region  and  their 
abundant  blood  supply  to  the  whole  vault  of  the  pharynx 
with  all  its  anfractuosities,  to  the  veil  of  the  palate,  to  the  buccal 
mucosa  and  to  the  nasal  fossae.  This  spread  of  the  strepto- 
coccic infection  is  important  from  the  view  point  of  the  ex- 
planation of  the  ocular  complications  which  it  is  able  to  pro- 
voke. Almost  always,  indeed,  it  is  observed  that  an  erysipelas 
occurring  or  beginning  in  the  nasal  fossa  shows  itself  without 
by  emerging  either  through  the  anterior  orifice  of  the  nose, 
or,  and  this  is  the  condition  which  interests  us  particularly, 
by  the  orifice  of  the  lachrymal  canal  at  the  internal  angle  of  the 
eye.  In  the  article  on  Er5^sipelas  in  the  Dictionary  of  Jaccoud, 
Maurice  Re3'naud  expresses  himself  thus — 'I  am  brought  to 
believe  that  the  greatest  number  of  cases  of  erysipelas  of 
which  the  first  manifestation  appears  as  a  red,  patch  at  the 
root  of  the  nose  have  in  reality  emerged  from  one  of  the 
lachrymal  points  and  have  taken  their  origin  in  the  corre- 
sponding nasal  fossa.'  It  is  indeed  this  manifestation  on  the 
part  of  the  lachrymal  channels  that  indicates  the  nature  of  the 
rhinitis  of  which  one  has  only  observed  the  external  mani- 
festation. It  is  in  fact  often  difficult  to  establish  the  diagnosis 
between  erysipelas  limited  to  the  nasal  mucosa  and  certain 
intense  coryzas — especially  those  whose  gener.al  symptoms 
present  in  a  majority  of  cases  an  unwonted  severity  and  in 
which  the  temperature  is  quite  elevated." 

Following  upon  this  theoretical  discussion  and  the  quota- 
tion of  the  views  of  men  of  wide  experience  and  keen  observa- 
tion allow  me  to  cite  concrete  instances  where  facial  erysipelas 
took  its  origin  in  or  from  the  nose,  the  accessory  nasal  cavitias 
or  the  ear. 

Mercier — Bellevue  (81)  in  commenting  on  a  case  of  facial 
Erysipelas  occurring  in  the  course  of  and  due  to  a  sinusitis  of 


ETIOLOGY   OF  ERYSIPELAS.  19 

the  maxillary  antrum  and  frontal  sinus  says:  "The  interesting 
point  in  this  observation  appears  to  me  to  reside  in  the  etiology, 
or  better,  the  pathogeny  of  this  case  of  facial  erysipelas  occur- 
ring abruptly  in  a  man  appearing  to  enjoy  excellent  health.  As 
I  said  in  my  opening  remarks,  the  complications  of  sinusitis  are 
as  numerous  as  they  are  frequent;  so,  on  the  one  hand,  one 
finds  on  the  part  of  the  sinus  the  explanation  of  those  gastro- 
intestinal or  pulmonary  affections  which  are  so  rebellious  to  all 
our  remedial  measures,  and  on  the  other  hand,  in  a  chronic 
or  acute  suppuration  of  a  cavity  of  the  face  one  can  find  the 
explanation  of  those  cases  of  recurrent  erysipelas  which  one 
combats  so  vigorously  but  which  one  cures  so  rarely  because 
one  does  not  know  the  real  cause  of  them."  In  the  course  of 
the  discussion  M.  Bessonnet  said  that  he  had  seen  erysipelas 
follow  simple  acute  coryzas. 

H.  Roger  (69)  made  personal  observation  of  957  cases  of 
erysipelas.  He  divides  them,  after  the  classic  authors,  into 
traumatic  and  nontraumatic — i.  e.,  into  those  in  which  an 
antecedent  wound  was  visible  and  those  in  which  no  wound 
or  abrasion  was  visible.  Their  distribution  was  as  follows : 
No.  of  Cases  Nontraumatic  Traumatic       Total 

Face 469 

Face  and  Neck 96 

Lower  Limbs 19 

Upper   Limbs 9 

Trunk 4 


M 

F 

M 

F 

M 

F 

183 

219 

35 

32 

218 

251 

24 

53 

15 

4 

39 

57 

3 

4 

6 

6 

9 

10 

2 

1 

4 

2 

6 

3 

2 

1 

2 

2 

2 

2 

597         214         278      62      46         274         322 
Nontraumatic — 4  9  2 . 
Traumatic — 108. 

In  488  cases  of  facial  erysipelas  the  distribution  was  as  fol- 
lows : 

Cheek 112  Scalp 24 

Internal  angle  of  eye 95  Forehead 17 

Base  of  the  nose 83  Upper    lid 12 

Lids 50  Temple 9 

Wings  of  nose 41  Top   of  nose 4 

Ears 36  Neck 2 

Chin 3 

Spohn  (77)  collected  by  circular  letter  the  details  of  1,000 
cases  of  erysipelas.  Nine  hundred  were  facial — of  the  facial 
the  beginning  point  of  the  disease  was — Scalp  3,  Cheek  3,  Lids 


20  ETIOI^OGY  OF  ERYSIPEIvAS. 

7,  Ears  60,  Lips  90,  Nose  737.    Eighty-two  per  cent  began  at 
the  nose. 

Spohn  concludes  "a  careful  examination  will  reveal  that  all 
or  nearly  all  cases  of  facial  erysipelas  unless  traumatic,  had  a 
previous  chronic  catarrh  and  a  partial  or  total  stenosis  of  one 
of  the  nostrils." 

Welty  (78)  of  San  Francisco  made  a  personal  examination 
of  some  60  cases  of  facial  erysipelas  which  he  reported  to  the 
Americal  Medical  Association.  Unfortunately  his  records  were 
destroyed  by  the  earthquake  and  fire  of  1906.  He  reports  from 
memory.  Eight  patients  had  more  than  one  attack  and  pus 
(in  the  nose)  was  always  demonstrated  in  their  cases.  The 
point  of  inoculation  in  a  large  majority  of  cases  was  about 
the  nose.  More  than  90  per  cent  complained  of  nasal  affections 
accompanied  with  a  discharge.  In  60  per  cent  of  the  whole 
number  of  cases  he  demonstrated  pus  in  the  ear  or  nose.  The 
bacteriologic  examination  of  30  cases  of  erysipelas  demon- 
strated streptococci  alone. 

Examination  of  secretions  from  ear  and  nose  showed  mixed 
infections — streptococci  always  present.  In  the  discussion  that 
followed  Farlow  of  Boston  reported  the  following  cases :  Man 
of  40.  Recurrent  erysipelas.  After  treatment  of  an  erosion  of 
the  septum  no  further  attacks  of  erysipelas. 

Patient  aged  50 — recurrent  erysipelas.  Treatment  of  an 
erosion  of  the  septum  prevented  further  attacks.  Woman  aged 
40 — recurrent  erysipelas.  Treatment  of  septal  erosion  pre- 
vented further  attacks.  Woman  aged  84 — -Facial  erysipelas.  T. 
103  and  a  tendency  to  coma.  Farlow  washed  out  the  nose, 
treated  a  septal  erosion  and  the  next  day  the  temperature  was 
nearly  normal.  Dr.  Mosher  of  Boston  said  that  a  routine  ex- 
amination of  the  nose  in  cases  of  erysipelas  had  been  the  custom 
at  the  Massachusetts  General  Hospital  for  years.  The  derma- 
tologists always  send  their  erysipelas  patients  to  the  Eye  and 
Ear  Infirmary  for  examination  of  the  nose. 

Stein  (79)  reports  a  case  of  chronic  nasal  catarrh;  acute 
exacerbation.  Neuralgic  pain  right  side  of  head — Occlusion 
right  nostril.  T.  105  F.  Rhinitis — Sinusitis — "Streptococci 
present  in  profusion."  On  the  third  day  "a  small  area  of  red- 
ness made  its  appearance  over  the  bridge  of  the  nose,  etc." 
Erysipelas.  Examination  of  vesicles  and  pustules  showed 
streptococci. 

In  cases  of  erysipelas  with  prodromal  fever,  as  occurred  28 


ETIOLOGY  OF  ERYSIPELAS.  21 

times  in  69  cases,  there  is  frequently  an  antecedent  affection 
of  the  throat.  The  erysipelas  spreads  to  the  skin  of  the  face 
through  the  nasal  passages,  the  lachrymal  canal  or  through 
the  Eustachian  tube  and  the  external  auditory  canal.  "Phy- 
siologic wounds" — clefts — are  present  in  the  mucous  mem- 
brane covering  the  lymphoid  tissue.  Gerhardt,  Berlin. 
Klinische  Wochenscrift— No.  3.  s.  45-1887. 

Clinical  observations  on  a  mild  case  of  erysipelas  which 
developed  from  a  chronic  scrofulous  rhinitis.  Arnaldo  Can- 
tini,  Bollet  delle  Cliniche  No.  2-188. 

Three  cases  of  chronic  antral  disease  which  had  annually 
passed  through  one  or  two  attacks  of  facial  erysipelas  for  the 
preceding  five  years.  After  operative  interference  upon  the 
antral  contents,  erysipelas  did  not  recur. — Hajek  Pathol,  u. 
Therap.  der  Entziind  Erkrank  der  Nebenhohlen  der  Nase, 
1899,  p.  77. 

Cases  of  erysipelas  of  the  pharyngeal  mucosa  are  rare,  but 
they  are  of  great  moment,  as  a  secondary  facial  erysipelas  may 
follow  on  a  primary  erysipelas  of  mucosa  of  the  nose,  throat 
and  mouth.  A  case  of  this  kind  occurred  in  Schwartze's  ear 
clinic.  A  patient  who  had  had  a  tonsil  lemoved  visited  another 
patient  with  erysipelas  and  thus  acquired  an  erysipelas  of  the 
nasopharynx  which  spread  through  the  Eustachian  tube  into, 
the  middle  ear,  the  external  canal,  the  auricle  and  the  face. 

Rendu  saw  a  man  with  specific  glossitis  in  whom  he  identi- 
fied erysipelas  by  bacteriological  examination.  The  erysipelas 
spread  to  the  face.    France  medicale,  1892. 

Erysipelas  of  the  mucous  membrane  of  the  nose  either  begins 
in  the  pharynx,  extends  through  the  nose  and  then  spreads 
over  the  face  or  it  progresses  in  the  opposite  direction. — Die 
Kranheiten  der  Nase,  Ihre  Nebenhohlen  und  des  Nasen: 
rachenranmes — Zarniko — Chap.  8  Rhinitis  purulenta  acuta — 
p.  166,  P.  472. 

Clergyman  aged  48.  Boil  in  the  nose.  Opened  after  7 
days.  T.  103  F.,  P.  110.  "Swelling  and  redness  of  the  nose 
was  marked  and  decidedly  erysipelatous  in  character."  Disease 
pursued  a  typical  course  except  that  there  was  some  involve- 
ment of  the  posterior  nares  and  the  pharynx,  and  later  more 
or  less  hemorrhage  from  the  bowels  for  a  week. — J.  M.  Har- 
wood,  Shelbyvjlle,  Ky.  American  Pract.  and  Neivs,  April  30th, 
1887. 

Case  I. — Child  aged  4.    Acute  nasal  catarrh  and  facial  ery- 


22  •      ETIOI^OGY  OF  ERYSIPEJLAS. 

sipelas  commencing  on  the  bridge  of  the  nose.  Warm  alkaHne 
nasal  injections  without  any  other  treatment  markedly  im- 
proved the  nasal  condition  and  the  erysipelas. 

Case  II. — Boy  aged  13.  Hypertrophic  nasal  catarrh.  Re- 
current attacks  of  erysipelas  of  nose  and  cheeks.  Treatment 
of  the  nose  caused  the  permanent  disappearance  of  the  ery- 
sipelas. 

The  reporter  also  says  he  has  notes  of  two  similar  cases 
of  his  own  and  four  of  his  colleagues.  "In  the  cases  referred 
to  above  the  erysipelas  always  commenced  on  the  bridge  of 
the  nose  and  was  greatest  on  the  side  of  the  greatest  pressure. 
There  was  no  condition  present  in  the  nasal  chambers  that  I 
could  recognize  as  of  an  erysipelatous  nature  in  any  of  them." 
— Geo.  W.  Major,  Montreal,  Can.  N.  Y.  Med.  Jour.,  Aug. 
10th,  1889. 

A  mechanic,  25  years  of  age,  developed  erysipelas  on  the 
left  side  of  his  face  after  a  cold.  (See  also  list  of  ocular 
complications  after  erysipelas.) — Leber,  Archiv.  f.  Ophth.,  Vol. 
xxvi,  Part  3,  p.  224. 

With  symptoms  of  a  pharyngitis  and  inflammation  of  the 
upper  passages,  pains  in  the  chest  and  difficulty  in  swallow- 
ing, a  woman  of  30  entered  the  hospital;  here  fever  and  de- 
lirium were  added.  In  9  days  a  facial  erysipelas  began  at  the 
nose.  In  a  few  days  it  disappeared  without  recurrence.  (See 
also  list  ocular  complications  after  erysipelas.) — Duroziez, 
Archiv.  de  Med.,  5  sec.  Txv,  s.  698. 

Case  I. — Man  aged  29.  Pharyngitis  and  slight  earache. 
Post-pharyngeal  abscess.  Incised  liberally;  three  or  four 
grams  pus.  Pharyngeal  tonsil  removed.  Two  weeks  later, 
acute  otitis  media.  Paracentesis  M.  T.  releasing  bloody  pus. 
Walls  of  pharynx  greatly  tumified  and  of  a  dusky  red.  The 
left  nasal  cavity  swelled  shut,  T.  103  F.,  and  erysipelas  now 
spread  from  nostril  over  entire  face.  Severe  case.  One  re- 
lapse.   Recovery. 

Case  II. — Woman  aged  25.  Facial  erysipelas  which  had 
arisen  at  the  right  nostril  spread  over  the  face  and  disap- 
peared. The  nasal  passages  were  swollen  and  the  pharynx 
reddened.  There  had  been  sore  throat  for  some  months ;  ear 
trouble  had  appeared  one  week  previously,  the'  M.  T.  bursting 
spontaneously.  Mastoid  tender.  T.  103,  P.  rapid  and  feeble. 
A  few  days  later  erysipelas  appeared  again  at  the  tip  of  the 
nose  and  spread  over  the  face. — H.  V.  Wurdemann,  Medical 
News,  Nov.  21st,  1891. 


ETIOLOGY  OF  ERYSIPELAS.  23 

Gasser  reports :  Erysipelas  about  the  left  orbit.  On  fourth 
day  a  flow  of  mucus  from  nostril,  pain  in  temporal  region, 
death  on  sixth  day.  Ethmoiditis  found  at  autopsy.  Quoted 
by  Fish,  Am.  Journ.  Surgery.,  Sept.,  1906. 

Vacher  (83)  of  Orleans  reported  to^the  Societe  beige  d'otol- 
ogie  a  case  of  facial  erysipelas  in  a  woman  which  followed  a 
paracentes-s  M.  T.  evacuating  blood  and  pus  in  the  course  of 
a  violent  otitis  and  mastoiditis.  She  had  suffered  for  a  num- 
ber of  years  from  a  chronic  dacryocystitis  in  which  the  sac  was 
daily  emptied  by  pressure,  the  mucopurulent  contents  being 
expressed  into  the  nose. 

A  women  of  38  developed  facial  erysipelas  which,  possibly 
originating  in  an  excoriation  at  the  right  ala  of  the  nose,  fol- 
lowed a  rapid  cooling  of  the  body.  The  lids  swelled  and  both 
eyes  protruded.  (See  also  list  of  ocular  complications  after 
erysipelas.) — Jager,  Ophthalmoskop.     Handatlas,  1869. 

Fig.  75— Plate  xvl : 

Man  aged  35.  Complained  of  exophthalmos  and  a  discharge 
from  the  nose  of  one  year's  duration.  Eye  displaced  down  and 
out.  Upper  lid  thickened  and  drooped,  covering  a  soft  swell- 
ing in  upper  part  of  orbit.  Pressure  on  swelling  caused  thick 
pus  to  appear  in  left  nasal  passage.  Ocular  mobility  restricted. 
Venous  congestion  of  retina.  Left  middle  turbinate  hypertro- 
phied.  Middle  meatus  contained  polypi  and  offensive  pus. 
Probe  detected  extensive  necrosis  ethmoid  cells.  Patient  ex- 
cellent health.  Futile  attempts  made  to  treat  the  case  by 
intranasal  operation,  but  disease  was  too  extensive.  Operation 
under  ether.  In  completing  external  incision  at  inner  orbital 
margin  an  abscess  cavity  was  opened.  Floor  and  inner  wall 
of  frontal  sinus  extensively  diseased  as  also  the  ethmoid  laby- 
rinth. The  sphenoidal  sinus  was  healthy.  Seventeen  days  after 
operation  erysipelas  appeared,  lasting  nine  days.  Recovery. — 
Arnold  H.  Knapp.  Archives  of  Ophthalmology,  Vol.  XXVIII, 
p.  50. 

Case  I. — Contagion  arising  from  abrasion  in  the  anterior 
nares  in  a  patient  who  was  in  the  habit  of  picking  the  nose 
and  who  had  visited  and  nursed  an  erysipeFas  patient  in  the 
neighborhood.  Acute  suppuration  in  the  left  middle  ear  occur- 
ring after  extension  of  the  erysipelas  to  the  nose  and  throat. 
Recovery  after  one  relapse.  Microscopic  examination  of  ear 
discharge  revealed  several  forms  of  pus  cocci  including  strep- 
tococci. 


24  ETIOI^OGY  OF  ERYSIPEI.AS. 

Case  II. — Beginning  in  an  abrasion  of  the  m.  m.  of  the 
lower  lip  in  a  pipe  smoker,  extending  through  the  buccal  cavity 
to  the  nasopharynx,  through  the  Eustachian  tubes  to  the  middle 
ears,  causing  suppuration.  Extension  to.  face  and  scalp.  No 
history  of  contagion.     Recovery. 

Case  III. — A  scrofulous  child  with  erosion  of  anterior  nares 
and  upper  lip  from  purulent  rhinitis.  Facial  erysipelas.  Re- 
covery. 

Case  IV. — An  old  man,  whose  nasal  passages  had  been 
occluded  for  years  by  an  enormous  number  of  polypi  the 
operations  for  which  were  made  daily  for  about  a  week.  Con- 
siderable malodorous  purulent  discharge  followed.  After  at- 
tempted disinfection,  the  galvano  cautery  was  used  and  two 
days  later  erysipelas  appeared  in  the  nares  extending  over 
the  face.  Recovery. — H.  V.  Wurdemann,  Med.  News,  Nov. 
10th,  1894. 

A  working  woman,  56  years  of  age,  poorly  nourished,  who 
suffered  with  chronic  rhinitis,  developed  facial  erysipelas  with 
involvement  of  the  lids.  (See  also  list  of  ocula:  complica- 
t'ons  after  erysipelas.) — Mitvalsky,  Klin.  Monatsbl.  f.  Augen- 
heilk,  1893 — s.  18 — Aschenborn,  Archiv.  f.  klin.  Chirurg., 
XXV— s.  154. 

A  primipara,  aged  33,  complained  of  pain  and  sensation  of 
tension  in  the  nose  on  the  day  of  delivery.  She  had  suffered 
from  nasopharyngeal  catarrh  in  the  last  days  of  her  pregnancy. 
Two  days  after  delivery  the  nose  and  the  lids  of  both  eyes 
were  so  swollen  that  the  eyes  could  not  be  opened.  Violent 
erysipelas  developed.  (See  also  list  of  ocular  complications 
of  erysipelas.) — Joss.  Correspondenzhl.  f.  Schweitzer  Aerzte 
Bd.  XXXI— 1901— s.  617. 

Laborer,  37  years  old.  Considerable  swelling  of  the  tongue, 
which  began  at  the  anterior  half  at  a  point  of  ulceration,  the 
result  of  a  carious  tooth.  The  swelling  was  so  great  that  the 
patient  could  not  close  the  mouth.  There  was  debility,  head- 
ache and  fever.  Violent  erysipelas.  In  the  course  of  a  few 
days  the  pharynx  and,  in  succession,  the  cheeks,  the  nares,  the 
eyelids,  the  ears  and  the  scalp  became  involved. — Garel,  An- 
nates des.  mal.  de  I'oreille,  May,  1891. 

"Cauterization  of  the  nasal  mucous  membrane  is  not  en- 
tirely free  from  risk.  Cases  have  been  met  with  in  which 
erysipelas  of  the  nose  and  face,  otitis  media,  ocular  troubles, 
such  as  amblyopia  and  venous  engorgement  of  the  eye  with 


ETIOLOGY  OP  ERYSIPELAS.  25 

papillary  hyperemia  have  occurred."  ....  "In  cases 
of  recurrent  erysipelas  of  the  face  the  pharyngeal  tonsil  has 
apparently  been  the  starting  point  of  the  erysipelas  and  it  is 
well  known  that  the  nose,  especially  when  affected  with  chronic 
rhinitis,  frequently  gives  rise  to  facial  erysipelas.  These  facts 
should  emphasize  the  importance  of  the  careful  examination 
of  the  nose  and  nasopharynx  in  cases  of  recurrent  erysipelas 
of  the  face  and  they  would  also  suggest  a  possible  mode  of 
origin  of  pharyngeal  and  laryngeal  erysipelas,  because  if  the 
disease  can  spread  externally  there  is  no  reason  why  it  should 
not  spread  internally." — Diseases  of  the  Nose  and  Throat, 
Hall  and  Tilly.    Second  Edition,  1901. 

Facial  erysipelas  occurring  in  a  case  of  melancholia.  "The 
patient  had  a  well  defined  facial  erysipelas,  beginning  on  the 
right  side  of  the  face  just  in  front  of  the  ear  and  in  the 
external  canal  of  the  left  ear,  from  which  came  a  seropurulent 
discharge."— /oMr.  Am.  Medical  Ass'n,  1900,  XLH,  p.  647. 

Woman,  aged  70.  Erysipelas  of  the  face  having  begun  at 
the  nasal  orifice  on  the  right  side,  involving  the  right  half  of 
the  nose  and  cheek.  Throat  red.  tongue  dry.  ( See  also  list  of 
ocular  complications  after  erysipelas.)— F.  Terrien,  Neurite 
et  atrophic  optique  au  cours  de  I'erysipele.  Progress  Med., 
Paris,  1904,  XX,  p.  165. 

In  addition  to  the  case  mentioned  in  the  discussion  of  Dr. 
Welty's  paper  at  the  meeting  of  the  American  Medical  Associa- 
tion, Dr.  John  Farlow  of  Boston  reports  the  following  cases: 

Case  I. — -Woman,  aged  40,  had  had  a  number  of  severe  at- 
tacks of  facial  erysipelas  at  frequent  intervals.  Marked  ero- 
sion of  the  septum.  Another  attack  of  erysipelas  threatened. 
Thorough  cleansing  of  the  nose  caused  the  symptoms  to  dis- 
appear and  she  went  nine  years  without  another  attack. 

Man,  53  years,  had  a  very  severe  attack  of  facial  erysipelas. 
Nose  examined  later  and  marked  septal  erosion  with  bloody 
crusts  found.  On  one  occasion  the  nose  became  reddened,  but 
treatment  of  the  septum  stopped  what  the  patient  feared  would 
be  another  attack  of  facial  erysipelas.  In  the  discussion  Dr. 
S.  Johnston  said  he  had  seen  one  case  of  facial  erysipelas  hav- 
ing its  origin  apparently  in  a  perforation  of  the  nasal  septum. — 
Trans.  25th  Ann.  Meeting  American  Laryngological  Assn., 
1903. 

In  Welty's  valuable  article,  besides  recording  his  own  ex- 
periences and  referring  to  nine  similar  reports  in  the  litera- 


26  ETIOI.OGY  OF  ERYSIPEI.AS. 

ture,  he  refers  to  the  following  presumably  unpublished  cases : 
"Dr.  Able  Johnson,  San  Francisco,  has  seen  four  cases  of 
erysipelas  in  European  clinics.  In  2  he  was  able  to  demon- 
strate pus  in  the  nose;  2  followed  surgical  interference,  1  for 
extensive  removal  of  polypi  accompanied  by  pus,  1  following 
the  removal  of  the  inferior  turbinated  in  which  pus  was  not 
demonstrated.     Dr.  Albert  Houston,  San  Francisco,  has  seen 

2  cases  follow  surgical  operations  on  the  nose  for  the  removal 
of  polypi.    In  the  Vienna  Nose  and  Throat  Clinic  I  have  seen 

3  cases  of  erysipelas  develop  while  the  patients  were  under 

treatment I  also  observed  3  cases  of  erysipelas 

following  mastoid  operations,  1  in  Halle  and  2  in  Vienna." — 
C.  F.  Welty,  Jour.  American  Med.  Assn.,  Dec.  22nd,  1906. 

Facial  erysipelas  being  such  an  extremely  common  disease 
and  the  microbic  cause  of  it  having  been  so  firmly  established, 
individual  cases  of  it  are  no  longer  reported  in  the  literature 
unless  for  the  purpose  of  noting  some  complications,  such  as 
meningitis,  intestinal  hemorrhage,  orbital  abscess  or  severe 
ocular  complications. 

So  few  have  as  yet  recognized  the  local  origin  of  the  infec- 
tion that  it  is  only  in  the  literature  of  rhinology  that  a  distinct 
exposition  of  the  predisposing  and  exciting  causes  may  be 
found.  Knowing,  however,  that  a  large  amount  of  valuable 
data  could  be  secured  upon  application  to  the  proper  sources 
of  knowledge,  I  addressed  a  circular  letter  to  the  members  of 
the  American  Laryngological  Society,  the  American  Otological 
Society,  the  American  Academy  of  Ophthalmology  and  Oto- 
Laryngology  and  the  American  Ophthalmological  Society. 

This  letter  solicited  replies  to  the  following  questions: 
A. — Have  you  had  any  cases  of  facial  erysipelas  (or  erysipelas 
of  other  parts  of  the  body)  which  you  could  consider  as 
due  to  disease  of  the  nose  or  its  accessory  sinuses  ? 
B. — Have  you  had   any  cases   of  erysipelas   following  upon 
operations  performed  upon  the  mastoid  for  either  acute 
'    or  chronic  disease? 
C. — Following  upon  operations  performed  upon  the  nose  for 

acute  or  chronic  disease? 
D. — Following  upon  operations  performed  upon  the  antrum 

of  Highmore  for  acute  or  chronic  disease? 
B. — Following  upon  operations  performed  upon  the  ethmoid 
cells  for  acute  or  chronic  disease? 


ET101.0GY  OF  ERYSIPEIvAS.  27 

F. — Following  upon  operations  performed  upon  the  sphenoid 

body  for  acute  or  chronic  disease? 
G. — Following  upon  operations   performed   upon  the   frontal 

sinus  for  acute  or  chronic  disease? 
H. — Have  you  had  any  cases  in  which  more  or  less  extensive 
damage  was  done  to  the  eye  as  the  result  of  an  attack  of 
facial  erysipelas,  and  if  so,  could  you  trace  the  cause  of  the 
erysipelas  in  these  cases?  Did  any  of  these  cases  have 
diseased  nasal  chambers  or  disease  of  the  accessory  cavi- 
ties? 

I  have  to  extend  my  sincere  thanks  to  the  gentlemen  of 
these  societies  for  the  very  large  number  of  synopses  of  ex- 
tremely interesting  cases  which  they  have  sent  me.  I  appre- 
ciate the  trouble  they  have  taken  and  hope  they  will  derive 
some  satisfaction  out  of  having  helped  to  clear  up  a  subject 
which  does  not  appear  to  be  entirely  clear  to  some  of  our 
co-ordinate  branches  of  medicine  and  surgery. 

The  answers,  as  I  append  them  below,  are  lettered  to  corre- 
spond with  the  letters  of  the  questions  as  given  above  for  ease 
of  reference. 

Cases  of  erysipelas  occurring  in  course  of  and  due  to 
disease  of  the  nose  or  accessory  sinuses,  ox  following  upon 
operations  upon  the  ear,  the  nose  or  the  accessory  sinuses : — 

J.  F.  Crouch,  Baltimore.  A. — ^One  case  due  to  infection  of 
ethmoidal  or  frontal  sinus.  B. — One  case.  Acute  mastoiditis. 
Operation.  Erysipelas  on  third  day.  Recovery.  C. — Two 
cases  of  excision  of  cartilage  of  septum.  Erysipelas  on  second 
day.  Recovery  without  effect  on  field  of  operation.  A. — 
Man  aged  53.  Disease  of  ethmoidal  sinus  of  right  side;  de- 
veloped erysipelas  of  lids  and  orbit  which  on  fifth  day  caused 
death,  with  symptoms  of  septic  meningitis. 

C.  M.  Reyher,  Garrett,  Ind.  B. — ^Had  the  following  per- 
sonal experience :  Tonsillitis,  acute  nasopharyngitis.  Infection 
of  the  middle  ears  through  Eustachian  tubes  by  douching  out  of 
pharynx  and  nose.  Acute  otitis  and  mastoiditis  right  and 
left.  Operation  on  both  mastoids.  Five  days  later  erysipelas 
spreading  over  face,  neck,  chest,  abdomen  and  back.  Duration 
of  erysipelas  attack,  3  months.  Operation  wounds  discharged 
for  5  months. 

A.  E.  Prince,  Springfield,  111.  A. — Four  or  five  cases  in 
conjunction  with  acute  mastoid  disease.  B. — 'One  case  follow- 
ing operation  for  acute  mastoid  disease. 


28  ETIOLOGY  OF  ERYSIPELAS. 

W.  H.  Haskins,  New  York.  B. — Two  cases  following 
operation  for  acute  nastoiditis.  Recovery  without  sequalae. 
One  doubtful  case  diagnosed  erysipelas,  but  may  have  been 
a  dermatitis  following  use  of  iodoform. 

Herbert  Harlan,  Baltimore.  B. — Woman  aged  71  years, 
Erysipelas  apeared  fifth,  day  after  operation  for  acute  mastoid 
disease.  Desperately  severe  case  for  four  or  five  weeks. 
Recovery. 

Geo.  F.  Hawley,  Chicago.  B. — Operation  for  acute  mastoid- 
itis. Fistulous  opening  remained.  Secondary  operation  per- 
formed. Notwithstanding  all  precautions  in  operation  and 
after-treatment,  erysipelas  on  third  day.  Had  not  been  a  case 
of  erysipelas  in  hospital  for  six  months  and  was  first  time 
patient  suffered  from  disease.  C. — Erysipelas  following  opera- 
tion for  fractured  nose.  Antiseptic  precautions  taken,  but  in 
vain.  Infection  may  have  taken  place  at  time  of  fracture  and 
laceration. 

R.  S.  Lamb,  Washington.    B. — Woman  aged  33.    Operation' 
for  acute  mastoid  disease.    Erysipelas  developed  on  fourth  day. 
Twelve  days  later  wound  reopened  and  necrotic  tissue  removed. 

Randolph  Brunson,  Hot  Springs,  Ark.  A. — Three  cases  of 
erysipelas  having  origin  in  suppuration  of  middle  ear.  One 
in  acute  suppuration,  two  in  chronic  suppuration.  A. — In  the 
course  of  a  chronic  suppuration  from  the  nose,  erysipelas  de- 
veloped and  extended  over  one  side  of  face,  having  its  origin 
in  nasal  cavity.  Duration  a  few  days.  .  D. — Same  cases  as 
above.  Operation  for  draining  suppurating  antrum  of  High- 
more  through  the  canine  fossa.  Two  weeks  later  erysipelas 
developed  and  traveled  over  same  side  of  face.  Duration  a 
few  days.  C. — After  operation  on  frontal  sinus  erysipelas 
developed,  apparently  from  external  wound,  and  patient  sub- 
sequently died  from  meningitis  during  time  erysipelas  was  at 
its  height.    Operation  under  bad  surgical  environment. 

J.  C.  Easton,  Springfield,  O.  A. — Facial  erysipelas  as  the 
result  of  an  abrasion  near  the  inner  canthus  of  right  eye. 
Spread  over  lids,  brow  and  right  side  of  face.  Acute  rhinitis 
part  of  the  time,  but  this  was  late  in  the  disease.  In  a  few 
days  there  was  sloughing  of  tissue  at  initial  point.  Incision 
made,  pus  evacuated.  On  probing  in  region  of  ethmoid  cells 
more  seropurulent  matter  evacuated.  (See  also  list  of  ocular 
complications  after  facial  erysipelas.) 

W.   Sohier  Bryant,   New   York.     A — Case  I. — A   case   of 


ETIOLOGY  O^  ERYSIPELAS.  29 

purulent  pansinusitis  with  facial  erysipelas  every  year  or  two. 
It  commenced  on  the  alae  nasi  or  on  upper  lip  close  to  nasal 
orifices  and  spreads  over  the  whole  head.  Case  II. — Case  of 
acute  purulent  rhinitis.  The  erysipelas  commenced  at  the 
orifices  of  the  nose  and  spread  over  cheeks  and  the  whole  head. 
B. — Has  recently  seen  in  consultation  a  severe  case  of  erysipe- 
las with  temperature  range  105  F.-106  F.,  and  profound 
sepsis  in  a  man,  following  a  mastoid  operation  consequent  to 
grip  infection.  Erysipelas  commenced  in  pinna  and  spread  to 
whole  head,  neck  and  back  down  to  buttocks. 

M.  A.  Hughes,  Salt  Lake  City.  A. — Man  aged  45  years. 
Small  ulcer  in  left  nostril  which  he  irritated  with  finger  nail. 
Erysipelas  of  all  accessory  sinuses  of  left  side  of  nose,  ulti- 
mately involving  eye  and  meninges  of  brain.  Death  from 
cerebral  involvement  on  sixth  day.  Patient  treated  conjointly 
with  the  late  Dr.  J.  McKenna. 

H.  S.  Birkett,  Montreal,  Can.  A. — Case  I. — A  girl,  10  years 
of  age,  suffering  from  atrophic  rhinitis,  developed  a  double 
acute  suppurative  frontal  sinusitis,  followed  during  the  course 
of  the  inflammatory  condition  by  an  attack  of  acute  erysipelas. 
It  showed  itself  over  the  region  of  both  frontal  sinuses  and 
extended  upward  to  the  middle  of  the  scalp.  Recovered  under 
the  use  of  antistreptococcus  serum.  Case  II.- — A  man,  aged  60 
years.  Erysipelas  showed  itself  over  the  nasal  bones  and  ex- 
tended slightly  on  to  both  cheeks,  due  (in  Birkett's  opinion) 
to  the  abusive  use  of  snuff.  No  recurrence  of  erysipelas  since 
the  discontinuance  of  the  use  of  snuff. 

N.  McKitterich,  Burlington,  la.  C. — Was  called  to  see  a 
supposed  case  of  la  grippe.  Slight  redness  and  swelling  of 
lower  portion  of  nose  was  present.  Learned  on  inquiry  of  a 
cauterization  of  enlarged  turbinal  shortly  before  onset  of 
illness.  Diagnosis  of  erysipelas  was  confirmed  by  rapid  spread- 
ing of  disease  and  death  on  fifth  day. 

Kaspar  Pischel,  San  Francisco.  A. — One  case  facial  ery- 
sipelas due  to  polypi  of  the  nose.  Cannot  give  synopsis  of 
history,  as  records  were  burned. 

John  E.  Weeks,  New  York.  A. — Physician,  aged  51,  had 
a  small  ulcer  on  the  septum  nasi,  right  side,  which  was  present 
more  or  less  constantly  for  a  number  of  years.  Character 
unknown.  Ulcer  about  two-thirds  of  the  distance  back  from 
the  anterior  nares.  Had  three  attacks  of  facial  erysipelas, 
originating,  according  to  the  testimony  of  the  patient,  who  was 


30  ETIOLOGY  OF  ERYSIPELAS, 

a  close  observer,  in  this  small  superficial  ulcer.    Ulcer  observed 
by  Dr.  Weeks  from,  time  to  time. 

H.  H.  Briggs,  Asheville.  A. — Male,  aged  47.  Otherwise 
healthy.  Seen  in  consultation.  Inflammation  beginning  in 
nostrils  as  if  from  an  acute  rhinitis.  Spread  all  over  face  and 
ears  and  on  to  the  scalp ;  also  into  the  pharynx  and  Eustachian 
tubes  and  to  the  middle  ear,  the  M.  T.  perforating.  The  head 
of  patient  was  much  swollen.  The  eyes  escaped,  although 
there  was  stenosis  (temporarily)  of  the  lachrymal  duct.  Not 
having  seen  patient  before  onset  of  disease,  do  not  know  if 
he  had  any  previous  accessory  sinus  involvement.  D. — B. — 
F. — G^.— Female,  aged  44.  Chronic  empyema  antrum  of  High- 
more,  sphenoidal  sinus,  anterior  and  posterior  ethmoid  cells 
and  frontal  sinus  on  left  side.  Ethmoid,  sphenoid  and  antrum 
operated  upon.  Nasal  duct  enlarged  into  frontal  sinus.  Finally 
opening  through  frontal  bone  was  made  and  sinus  curetted. 
Patient  went  home  and  some  weeks  later  had  an  erysipelas 
about  the  fistulous  opening.  Process  was  arrested  by  treat- 
ment. 

L.  C.  Cline,  Indianapolis.  B. — ^Male,  aged  26.  Operation 
for  chronic  mastoid  disease.  Five  days  later  erysipelas  ex- 
tending above  and  to  the  front,  involving  the  eyelids  and  caus- 
ing a  superficial  abscess  above  and  in  front  of  the  ear.  D. — 
Two  cases  after  operation  upon  the  antrum  of  Highmore. 
Recovery  without  complications. 

\N.  H.  Peters,  Lafayette.  A. — Fissures  of  the  vestibule  were 
present  in  two  cases  preceding  the  disease.  A. — "J-  '^-  S., 
embalmer,  aged  31,  came  for  an  operation  for  deviation  of 
septum.  It  was  on  Saturday.  I  postponed  the  operation  until 
Tuesday.  On  Tuesday  morning  he  came  with  a  T.  103.6  F,, 
and  I  referred  him  to  his  family  physician.  Erysipelas  ap- 
peared within  twenty-four  hours,  beginning  on  the  side  of 
the  nose  in  which  I  was  to  have  operated,  covering  the  whole 
head,  neck  and  front  of  the  chest  below  the  nipple  line. 
There  were  abscesses  of  both  tear  sacs,  of  the  antrum  of 
Highmore  on  the  occluded  side,  and  extensive  abscesses  of 
the  scalp.  The  patient  recovered ;  but  if  I  had  operated  at  the 
appointed  time,  namely,  on  the  day  he  consulted  me  (Satur- 
day), no  man  living  could  have  convinced  me  that  the  opera- 
tion had  not  caused  the  erysipelas,  though  not  necessarily 
through  any  fault  of  mine." 

W.  H.  Dudley,  Los  Angeles.    A. — Has  seen  erysipelas  occur 


ETIOLOGY  OF  ERYSIPELAS.  31 

following  throat  inflammations  and  acute  ear  conditions.  His 
records  are  not  at  present  accessible  to  him. 

H.  O.  Reik,  Baltimore.  B. — One  case  following  acute  otitis 
media  suppurativa,  beginning  December  2oth.  Mastoiditis, 
with  extensive  subperiosteal  abscess  extending  in  front  of 
auricle.  Long  neglect.  Operation  early  in  February,  ihree 
weeks  later,  returning  for  dressing,  was  found  to  have 
facial  erysipelas.  Serious  illness  followed.  Cured  by  anti- 
streptococcus  serum.  Pneumococcus  from  ear  and  mastoid, 
B. — One  case  after  tympano-mastoid  exenteration.  Like  the 
first  case  it  occurred  weeks  after  the  operation,  but  while 
dressings  were  still  being  made.     Mild  case. 

Ford, .    A. — One  case  of  chronic  suppurative 

otitis  media  gives  a  history  of  two  attacks  of  erysipelas. 

G.  P.  Head,  Chicago.  A. — Boy  of  15.  Very  marked  devia- 
tion of  septum.  Almost  complete  occlusion  of  one  side.  Had 
had  a  vestibulitis  for  some  weeks.  Erysipelas  began  at  edge 
of  right  ala  nasi  and  spread  over  right  cheek  and  nose. 

S.  D.  Risley,  Philadelphia.  A. — "One  case  following  or 
possibly  beginning  in  the  right  nostril  of  a  patient  with  chronic 
rhinitis  and  an  enlarged  middle  turbinate  with  much  stuffing 
of  the  nostril.  Came  on  like  an  acute  coryza  and  rapidly 
developed  into  an  attack  of  violent  erysipelas,  spreading  to 
both  sides  of  the  face." 

J.  W.  Ingalls,  Brooklyn.  A. — "Necrosis  of  septum.  It  is 
probable  that  there  was  involvement  of  the  accessory  cavities. 
(The  case  came  under  my  care  twenty  years  ago  when  but 
little  attention  was  given  to  the  accessory  cavities.)  In  the 
course  of  six  years  she  had  three  attacks  of  facial  erysipelas." 

L.  R.  Ryan,  Galesburg.  B. — Case  I. — Sister  of  Charity, 
aged  30.  Acute  mastoiditis.  Intense  pain,  moderate  fever  and 
swelling.  Wilde's  incision  made.  Immediate  relief.  Patient 
died  in  a  few  days  from  what  the  attending  physician  diagnosed 
as  erysipelas.  Ryan  saw  the  case  but  once.  Case  II. — ^Woman 
of  70  years  operated  upon  for  senile  cataract.  Erysipelas 
developed  within  twenty-four  hours,  involving  nose,  cheeks 
and  forehead.  Cornea  sloughed  and  eye  was  lost.  Afterward 
discovered  pus  deep  in  duct,  also  some  involvement  of  the 
ethmoid.     Case  was  undoubtedly  of  nasal  origin. 

W.  E.  Casselberry,  Chicago.  B. — Girl,  aged  20.  Purulent 
bilateral  nasal  discharge,  polypoid  degeneration  of  both  middle 
turbinals.    Puncture  and  irrigation  of  antra  negative.    Frontal 


32  ETIOLOGY  OF  ERYSIPEI^AS. 

probably  negative.  Thickening  of  nasal  bridge.  History  of 
thirty  attacks  of  facial  erysipelas  during  the  past  six  years, 
mostly  commencing  within  the  right  naris  and  striking  through 
the  nasal  bridge.  All  degrees  of  severity.  Bilateral  middle 
turbinectomy,  ethmoidal  cell  curettage.  Treatment  incomplete, 
having  been  interrupted  by  attack  of  erysipelas.  A. — Two 
cases  facial  erysipelas  which  commenced  within  the  nostrils 
without  any  special  or  known  antecedent  nasal  disease.  C. — 
Man,  aged  55.  Sharp-forceps  removal  of  a  few  polyp-buds 
from  middle  meatus,  followed  within  a  week  by  a  severe 
facial  erysipelas  which  commenced  in  that  nostril.  Not  a  pus 
case  before  or  since,  as  several  years  elapsed  without  the  de- 
velopment of  any  serious  degree  of  ethmoidal  or  sinus  disease. 
C. — Man,  aged  40.  A  case  similar  to  above,  but  exact  details 
not  remembered  or  recorded. 

Unsigned  communication  from  some  member  of  the  Ameri- 
can Academy  of  Ophthalmology  and  Oto-Laryngology,  the 
American  Otological  Society,  or  the  American  Ophthalmologi- 
cal  Society.  A. — Man,  aged  63.  Acute  mastoiditis  with  ery- 
sipelas. Operation.  Whole  mastoid  necrotic.  Eruption  spread 
over  the  whole  body  twice  and  half  the  body  the  third  time. 
Patient  comatose  five  days.  Recovery.  B. — Operation  for 
acute  mastoiditis.  Woman,  aged  39.  Erysipelas  commenced 
on  lobe  of  opposite  ear,  covered  half  of  head  and  shoulder,  but 
did  not  involve  the  wound  or  the  operated  side  of  body.  Re- 
covery. B. — Girl  of  17.  Operation  for  acute  mastoiditis. 
Erysipelas  of  opposite  side  of  head.  Recovery.  G. — Case 
seen  in  hospital  service  of  a  colleague.  Frontal  sinus  opened 
externally.     In  six  to  ten  days  erysipelas  developed. 

Hiram  Woods,  Baltimore.  B. — Case  I. — Child.  Mastoiditis 
in  course  of  scarlet  fever.  Operation  followed  by  erysipelas 
starting  from  tragus.  Case  II. — Man,  whole  head  involved 
third  day  after  operation.  Case  III. — Erysipelas  following 
incision  of  M.  T.  for  acute  otitis  media.  Case  IV. — Erysipelas 
following  removal  of  polypi  from  external  auditory  canal. 
Case  V. — One  case  appearing  six  days  after  the  radical  opera- 
tion for  chronic  mastoiditis. 

Frank  C.  Todd,  Minneapolis.  A. — Hospital  nurse,  aged  25. 
Nov.  20th,  1906,  was  taken  with  a  severe  "cold"  in  the  head 
characterized  by  profuse  discharge  from  both  nostrils,  pain  in 
frontal  sinus  and  region  of  both  antra;  fever,  general  malaise. 
Dr.  Todd  called  Nov.  24th.    Diagnosis,  acute  sinusitis,  frontal 


ETIOLOGY  OF  ERYSIPELAS.  '  33 

and  ethmoidal,  with  probable  involvement  of  antra.  Same 
day  there  became  manifest  erysipelatous  eruption  which  later 
covered  nose,  region  over  frontal  sinus  and  down  on  to  the 
cheeks  for  a  short  distance.  Severe  attack.  T.  105  3/5  F., 
P.  126.  Possible  history  of  previous  sinus  trouble.  Case  of 
Drs.  Benjamin  and  Wright.     Discharged  cured  Dec.  7th. 

J.  R.  Mcintosh,  St.  John,  N.  B.  G.—"l  have  seen  at  least 
two  cases  of  frontal  sinus  disease  looked  upon  as  erysipelatous 
by  others.  I  regret,  however,  I  could  not  agree  with  that 
opinion  in  these  cases,  considering  it  simply  inflammatory  and 
due  to  repeated  subacute  attacks  of  frontal  sinus  disease.  , 
I  also  know  of  a  friend  of  mine  being  treated  for  some  high 
nasal  trouble.  Erysipelas  followed  and  death  resulted.  In  this 
case  I  know  the  operator  (now  also  dead)  had  atrophic 
rhinitis." 

Chas.  N.  Cox,  Brooklyn.  D. — One  case  of  erysipelas  fol- 
lowing operation  for  removal  of  sarcoma  of  antrum  involving 
also  nasal  cavity,  ethmoid  cells  and  orbital  plate.  Recovery. 
Progress  of  malignant  disease  seemed  to  be  stayed.  Patient 
lived  one  and  a  half  or  two  years  and  then  died  of  recurrence. 

Thos.  J.  Harris,  New  York.  B. — Erysipelas  following  upon 
secondary  operation  for  acute  mastoid  disease.  Erysipelas 
mild.  Did  not  retard  healing  or  involve  wound.  D. — Opera- 
tion upon  antrum  for  disease  induced  by  fibroma  of  naso- 
pharynx. Erysipelas  severe  but  did  not  extend  beyond  face. 
A. — Repeated  attacks  of  facial  erysipelas  on  side  correspond- 
ing to  diseased  ethmoid.     Mild  in  nature. 

C.  R.  Holmes,  Cincinnati.  C. — Sister  of  Charity,  aged  26. 
Erysipelas  three  days  after  turbinectomy.  Patient  had  a 
severe  chronic  ethmoiditis  and  the  operation  was  necessary  to 
secure  space  in  which  to  attack  the  ethmoid.  Attack  mild. 
A. — 'Man,  aged  38.  Involvement  of  all  cavities  on  right  side, 
chronic,  with  acute  exacerbations.  Operations  upon  inferior 
and  middle  turbinate,  ethmoid,  frontal  and  antrum.  Mild 
attack  of  erysipelas  during  convalescence.  B. — Woman,  aged 
25.  After  operation  for  chronic  mastoiditis  in  which  there  was 
extensive  destruction  of  bone.  Erysipelas  on  thirteenth  day. 
Case  of  average  severity  lasting  two  weeks.  B. — Woman, 
aged  67.  Operation  for  severe  acute  mastoiditis.  In  forty- 
eight  hours  erysipelas  rapidly  spreading  forward  from  eax. 
Mild  attack  lasting  three  days.  G. — Man,  aged  46.  History 
of  alcoholic  excesses.     Pansinusitis  R.  &  L.     Chronic  case  with 


34  ETIOLOGY   OF  ERYSIPELAS. 

frequent  exacerbations  of  inflammation  in  frontals.  External 
operation  opening  both  frontal  sinuses  during  acute  attack- 
Erysipelas  followed  immediately.  Severe  attack,  lasting  two 
weeks.    Corneal  ulcer. 

C.  Barck,  St.  Louis.  B. — One  case.  Emergency  operation, 
without  facilities  for  asepsis  or  antisepsis.    Recovery. 

W.  Cheatham,  Louisville,  Ky.  A. — Three  cases,  with  oc- 
casional relapses  attributed  to  small  abrasions  in  the  nose. 
Chronic  nasal  catarrh  with  excessive  secretion  and  nasal  en- 
gorgement. 

O.  A.  Griffin,  Ann  Arbor.  A. — Woman,  aged  50.  Deviation 
of  septum.  Enlarged  middle  turbinated-ethmoidal  disease. 
Developed  erysipelas  in  afifected  side  of  nose,  which  spread  to 
face.  Severe  case.  Recovery  with  more  profuse  discharge 
from  nose. 

Edw.  J.  Bernstein,  Kalamazoo,  Mich.  A. — Man,  aged  50. 
Good  health.  Empyema  antrum  of  Highmore  due  to  necrosed 
molar  tooth.  Erysipelas  made  its  appearance  at  lachrymal 
sac  and  spread  over  face.     Death  in  twelve  days 

Thos.  F.  Keller,  Toledo.  ^.—Patient,  aged  67.  Erysipelas. 
following  paraffin  injection  for  saddle  nose.  Excessive  hyper- 
emia and  dryness  of  m.  m.  nose.  A. — Woman,  aged  38. 
Recurrent  erysipelas  due  to  antral  disease  and  rhinitis.  At- 
tacks have  ceased  since  operation  and  cure  of  antrum. 

Geo.  F.  Keiper,  Lafayette.  B. — Double  operation  for  double 
mastoiditis.  Both  wounds  infected.  Recovery,  but  with  little 
filling  up  of  mastoid  wounds. 

Ray  Connor,  Detroit.  B. — Girl,  aged  11.  Double  mastoid 
operation  six  years  previously.  Chronic  discharge  since. 
Acute  abscess.  Radical  operation  done.  Eleven  days  later, 
skin  grafting.  Four  days  later,  erysipelas  of  five  days'  dura- 
tion. C. — Girl,  aged  18.  Erysipelas  following  removal  of 
tonsils  and  adenoids. 

Wm.  R.  Dabney,  Marietta.  ^.—Recurrent  erysipelas  in  man 
due  to  chronic  frontal,  anterior  ethmoid  and  bilateral  maxillary 
antrum  disease.  Erysipelas  always  preceded  by  acute  exacerba- 
tion of  above  chronic  conditions.  After  cavity  disease  had 
yielded  to  treatment  erysipelas  did  not  recur  during  life  of 
patient.  12  years.  A. — One  case  facial  erysipelas  in  a  chronic 
antral  suppuration.  B. — Erysipelas  following  operation  for 
acute  mastoiditis  in  which  the  streptococcus  was  the  organism 
present  in  the  mastoid.    Recovery. 


ETIOLOGY  OF  ERYSIPELAS.  35 

W.  F.  Mittendorf,  New  York.  A.—Rzs  had  two  or  three 
cases. 

D.  E.  Esterley,  Topeka.  B. — Acute  mastoiditis  following 
diphtheria.  Simple  operation.  In  a  few  days  erysipelas. 
Throat  greatly  inflamed  from  a  secondary  mixed  infection. 
Nephritis.    Death. 

Edgar  A.  Forsyth,  Buffalo.  ^.— Boy,  12  years.  Chronic 
rhinitis.  Erysipelas  of  nose  and  cheek  after  acute  exacerba- 
tion of  rhinitis. 

F.  Park  Lewis,  Buffalo.  B. — Erysipelas  following  mas- 
toidectomy for  acute  suppurative  inflammation.  Erysipelas 
was,  at  the  time,  in  the  hospital,  but  not  in  the  ward  contain- 
ing this  patient. 

Wolff  Freudenthal,  New  York.  ^.— One  case  seen  in  Ger- 
many. Recurrent  erysipelas  for  twenty  years  due  to  atrophic 
rhinitis  with  crust  formation.  One  or  two  attacks  a  year, 
sometimes  severe.  Has  seen  from  three  to  six  similar  cases 
in  New  York.  B. — "Doubtful  case.  Lady,  69  years  of  age, 
had  the  ethmoid  cells  scraped.  Two  days  later  she  telephoned 
she  had  some  fever.  In  spite  of  this  she  left  for  Europe  the 
next  day.  The  nose  and  part  of  the  face  was  swollen  and 
red.  She  died  in  mid-ocean."  Dr.  Freudenthal  did  not  see 
her  between  date  of  operation  and  date  of  departure. 

Horace  M.  Starkey,  Rockford.  B. — Boy  of  15.  Mastoid 
antrum  and  cells  filled  with  pus.  Lateral  sinus  and  dura  un- 
covered, but  appeared  normal.  T.  fell  to  nearly  normal  and 
patient  did  well  for  two  days.  Erysipelas  supervened  and 
quickly  carried  off  patient  by  meningitis.  Family  lived  on 
farm  five  miles  from  small  town.  No  other  case  of  erysipelas 
was  known  in  the  region.  Dr.  Starkey  had  not  seen  a  case 
of  erysipelas  for  two  years,  and  his  instruments  had  never 
been  near  a  suspicious  case. 

Henry  B.  Hitz,  Milwaukee.  B. — Woman,  36  years.  Acute 
mastoiditis  secondary  to  influenza.  Complete  ablation  of  tip 
and  zygoiTiatic  cells.  Abscess  cavity  located  in  tip  close  to 
the  junction  of  apophyses  with  squamous  portion.  It  con- 
tained a  pure  culture  of  streptococci.  Four  days  after  opera- 
tion erysipelas  developed  and  extended  over  face,  head,  neck, 
back,  to  buttocks,  and  down  left  arm.  Recovery.  D. — One 
case,  chronic.  Antrum  full  of  pus  and  caseous  matter  and 
necrotic  polypi.  Radical  operation.  Mild  attack  of  erysipelas 
involving  right  side  of  face. 


36  ETIOI.OGY  OF  e;rysipei,as. 

J.  G.  Dorsey,  Wichita.  A. — Two  cases  accompanying  sup- 
purative otitis  media. 

E.  F.  Reamer,  Mitchell,  S.  D.  ^.— Woman  of  35.  "Coin- 
cident with  an  acute  exacerbation  of  a  chronic  nasal  catarrh." 

E.  A.  Kegley,  Cedar  Rapids.  C. — Chronic  dacryocystitis 
R.  &  E-  Successful  operation  on  one  sac  and  duct.  Operation 
on  other  was  followed  on  third  day  by  erysipelas.  Dr.  Kegley 
lost  sight  of  patient,  but  was  informed  she  had  corneal  ulcers, 
which  healed,  leaving  a  useful  eye. 

U.  B.  G.  Ewing,  Richmond,  Ind.  A. — Woman  had  a  severe 
coryza.  Abrasions  occurred  from  mopping  nose  with  hand- 
kerchief.    Erysipelas  followed. 

Otto  J.  Stein,  Chicago.  A. — Woman.  Acute  purulent  rhi- 
nitis associated  with  an  erysipelas  that  extended  to  both  sides 
of  the  face. 

A.  J.  Knapp,  Evansville.  B. — Female,  aged  45.  Acute 
otitis  media  suppurativa  following  tonsillitis.  Spontaneous 
rupture.  M.  T.  Mastoiditis.  Streptococcus  infection.  Op- 
eration third  day.  Erysipelas  at  mastoid  wound  migrating 
over  face,  scalp,  neck  and  shoulders.  Recovery.  B. — Female, 
aged  12.    Case  similar  in  every  respect  to  the  preceding  one. 

H.  A.  Beaudoux,  Fargo,  N.  D.  C. — Partial  turbinectomy. 
Patient  later  fell  off  his  bicycle  and  sustained  a  slight  abrasion 
of  bridge  of  nose.    Erysipelas  followed. 

E.  E.  Foster,  New  Bedford,  Mass.  Operation  for  chronic 
purulent  ethmoiditis.  The  second  day  after  operation,  swell- 
ing occurred  on  the  side  of  the  head  operated  upon,  and 
temperature  rose  to  104,  where  it  remained  for  24  hours,  when 
it  rapidly  disappeared,  as  did  the  swelling.     Doubtful  case. 

J.  A.  Huizinga,  Grand  Rapids.  A. — Attempt  to  dislodge 
a  piece  of  dried  mucus  from  the  nose  with  a  hairpin.  Ery- 
sipelas followed.  Severe  case  with  meningeal  irritation.  B. — • 
Erysipelas  following  mastoid  operation.  Original  source  of 
infection  may  have  been  external  auditory  canal  before  case 
was  operated  upon. 

Ernest  V.  Buskman,  Wilkesbarre.  B. — Three  days  after  a 
mastoid  operation  on  the  right  side,  erysipelas  developed  in 
the  left  ear  and  left  side  of  face.  The  wound  did  not  be- 
come infected. 

F.  Vinsonhaler,  Little  Rock.  A. — One  case  originating  in 
pustule  in  tip  of  nose.     B. — One  mild  case  two  week?  a:fter 


ETIOI^OGY  OF  ERYSIPELAS.  37 

operation.     C. — One  case  following  cauterization  of  inferior 
turbinate. 

H.  Gifford,  Omaha.  C— Man.  Sunken  nose  bridge.  (  His- 
tory negative  and  symptoms  of  lachrymal  obstruction  on  left 
side.)  A  large  probe,  No.  11  or  12,  was  passed  directly  from 
the  tear  sac  into  the  nose  with  very  little  resistance.  The 
inner  wall  of  the  lachrymal  depression  evidently  was  gone. 
This  was  immediately  followed  by  a  severe  attack  of  erysipelas, 
spreading  from  the  inner  angle  of  the  eye.  When  this  was 
over  the  man  had  no  further  trouble  with  lachrymal  obstruc- 
tion.   10-12  years. 

W.    K.   Rogers,    Columbus,    O.     5.— Erysipelas    developed 
about  one  week  after  an  operation  for  mastoid  empyema  with 
septic  sinus  thrombosis,  involving  deep  ligation  of  the  internal 
jugular.     The  petrosal   sinuses   had  also  been   infected  and 
there  developed  a  large  retropharyngeal  abscess.     During  con- 
valescence a  catarrhal  appendicitis  and  pleurisy,  with  effusion, 
developed.     C — One  case  following  simple  tonsillotomy.     " 
^  Chas.  H.  May,  New  York.    5.— One  case  follwoing  opera- 
tion for  acute  mastoiditis.     Ward  case  in  Mt.  Sinai  Hospital 
ten  years  ago.     Details   unobtainable.     C— Man.     Alcoholic 
history.     Chronic  dacryocystitis.     Exsection  of  lachrymal  sac. 
Twenty-four  to   forty-eight  hours   later  erysipelas   developed, 
starting  from  the  region  of  the  wound.     Meningeal  symptoms 
and  death.    Mt.  Sinai  Hospital. 

T.  W.  Moore.  Huntington,  W.  Va.  ^.— One  case  following 
abrasion  of  the  lip. 

J.  Leslie  Davis,  Philadelphia.  M.— Two  cases  originating 
from  an  ulcerated  lesion  on  anterior  nasal  septum.  In  both 
cases  the  patients  had  been  picking  at  the  irritated  crusted  spots, 
and  with  the  facial  swelling  there  was  a  coexistent  acute  swell- 
mg  of  the  nasal  mucous  membrane  which  subsided  with  the 
clearing  up  of  the  facial  symptoms. 

Francis  P.  Emerson,  Boston.  ^.—1901,  September  12th, 
Mrs.  C.  H.  S.,  aged  53.  Left  facial  erysipelas  subacute,  1902^ 
October  2d,  left  facial  erysipelas  subacute.  Distinct  history  of 
left  supraorbital  pain  at  intervals  for  two  years  becoming  more 
frequent.  Examination  showed  a  polypus  between  left  middle 
turbinal  and  outer  wall.  Spongy  tissue  about  nasofacial  duct 
and  some  crusting.  Patient  had  used  finger  in  naris.  Re- 
moving polypus  and  opening  and  draining  an  ethmoidal  cell 
cured  the  case.     No  recurrence  of  erysipelas  in  five  years. 


38  ETIOLOGY  OF  ERYSIPELAS. 

S.  L.  Ledbetter,  Birmingham.  A. — Two  cases.  Males,  suf- 
fering from  catarrhal  conditions.  Erysipelas  started  in  nose, 
spread  to  face.  In  both  cases  perhaps  infection  from  finger. 
Recovery.  A. — One  case.  Male,  aged  70.  Erysipelas  began 
in  nose,  spread  to  face,  head,  neck.  Edema  of  glottis.  Death. 
A. — One  case.  Female.  Chronic  ethmoiditis.  Recurrent  ery- 
sipelas. Ethmoid  cells  cleaned  out.  Erysipelas  has  not  re- 
turned for  one  year.  C. — Male,  about  34  years.  Septal  opera- 
tion by  another  physician.  Erysipelas  began  in  nasal  orifice 
extending  to  face,  scalp  and  chest.     Recovery. 

EdAv.  J.  Brown,  Minneapolis.  ^4.— Mrs.  W.,  aged  53  years. 
Erysipelas  of  forehead  and  cheek  following  right  acute 
dacryocystitis.  Nasal  suppuration.  A. — Fred  C.  S.,  32  years. 
Erysipelas  below  right  auricle  following  purulent  inflamma- 
tion in  floor  of  external  canal.  Right  middle  turbinal  degene- 
rated and  polypoid  and  sinus  suppuration  for  years. 

L.  E.  Maire,  Detroit.  B. — One  case  following  operation 
for  purulent  mastoiditis.     Recovery. 

W.  H.  Merrill,  Lawrence,  Mass.  A. — Erysipelas  began  on 
inner  margin  left  lower  lid  after  phlegmonous  inflammation 
of  left  nostril  had  existed  two  days.  A. — Two  cases  where 
infection  began  in  nasal  vestibule.  End  of  nose  and  nasal 
mucous  membrane  involved  and  in  forty-eight  hours  empyema 
of  the  antrum  of  Highmore.  B. — Three  cases.  Acute  strepto- 
coccus infection  of  middle  ear  and  mastoid.  Marked  swelling 
and  edema  before  operation.  Erysipelas  followed  operation  in 
twenty-four  hours.     Recovery. 

J.  F.  Byington,  Battle  Creek.  B. — Woman.  Acute  mastoid- 
itis. Bacteriological  examination  at  the  time  of  operation 
showed  streptococcus  infection.  Severe  erysipelas  followed 
on  evening  of  second  day.  No  intracranial  involvement. 
Operation  performed  in  new  operating  room'  and  neither 
operator  or  assistants  had  seen  a  case  of  erysipelas  for  a  long 
time.  The  infection  was  evidently  from  the  pus  in  the  mastoid 
antrum.     Death  on  eighth  day. 

Wm.  Merle  Carhart,  New  York.  A. — Erysipelas  followed 
infection  of  the  nose  by  an  acute  process  involving  the  ethmoid 
cells  and  entire  nasal  cavity  of  one  side.  Infection  was  at 
first  a  staphylococcus  process  of  virulent  type. 

Guy  E.  Noyes,  Columbia,  Mo.  A. — Woman,  aged  30.  In 
the  forty-eighth  day  of  typhoid.  Loss  of  hearing  due  to 
Eustachian  occlusion.    The  mucous  membrane  of  the  nose  and 


ETIOLOGY  OF  ERYSIPELAS.  39 

pharynx  were  dry  and  covered  with  crusts  which  left  bleed- 
ing areas  when  detached,  as  is  usually  seen  in  typhoid. 
Catheterization  of  tubes,  inflation  of  middle  ear  without  satis- 
factory results.  One  week  later  acute  suppurative  otitis  media 
R.  &  L.  Three  days  later  facial  erysipelas.  Death  on  fifty- 
fourth  day  of  typhoid. 

L.  D.  Brose,  Evansville.  A. — Male,  aged  36.  Perforating 
ulcer  of  septum.  Erysipelas  spreading  from  ala  nasi.  C. — 
Male,  aged  about  45  years.  Acute  exacerbation  of  hypertro- 
phic nasal  catarrh.  After  an  application  of  the  galvano-cau- 
tery  to  the  right  inferior  turbinated  body,  had  a  severe  attack 
of  facial  erysipelas.  Recovery  with  an  active  perforating  ulcer 
of  the  septum. 

Chas.  H.  Baker,  Bay  City.  .4.— Male,  aged  45.  Chronic 
scabbing  left  septum.  Eczematous  crack  in  vestibule.  Facial 
erysipelas  that  side  of  face  starting  at  the  crack.  B. — Three 
cases  four  to  seven  days  after  operation.  Mild  attacks.  One 
case,  severe  attack  followed  by  severe  eczema  of  head  and 
body.     Recovery. 

Albert  E.  Bulson,  Jr.,  Ft.  Wayne,  Ind.  A. — Case  of  coryza 
from  influenza  complicated  by  erysipelas.  B. — Acute  exacer- 
bation of  a  chronic  suppurative  otitis  media.  Radical  mastoid 
operation.  In  forty-eight  hours  facial  erysipelas,  beginning 
at  the  mastoid  wound.  Recovery.  Another  case  somewhat 
similar  but  milder.  C. — Erysipelas  following  application  of 
electro-cautery  to  the  inferior  turbinal.  Has  never  had  two 
or  more  cases  in  succession  and  does  not  know  that  any  of  his 
cases  contracted  the  disease  from  other  cases  of  erysipelas  in 
hospitals  or  anywhere  else. 

W.  E.  Sauer,  St.  Louis.  C. — Female,  aged  28  years.  Four 
days  after  submucous  resection  of  the  septum  erysipelas  of 
four  weeks'  duration.     Recovery. 

Eugene  Smith,  Detroit.  B. — 'Erysipelas  of  vicinity  of  wound 
and  scalp  of  several  days'  duration  following  operation  for 
acute  disease.  Recovery.  B. — Erysipelas,  severe,  following 
operation  for  chronic  disease  in  poorty-nourished  patient. 
Recovery. 

M.  V.  Ball,  Warren,  Pa.  A. — Man,  aged  40.  Erysipelas 
originating  in  furuncle  of  nose.  Infection  from  finger  pick- 
ing crust.  Recovery.  A. — Man,  aged  35.  Good  history. 
Infection  from  a  small  furuncle  in  nose.  No  disease  of  nasal 
chambers  known  previously,  pneumonia,  septic,  delirium,  both 


40  ETIOLOGY  OP^  ERYSIPELAS. 

orbits  immensely  swollen  and  erysipelatous  inflammation  of 
skin  over  forehead  and  lids.  Death  in  three  days  from  general 
pyemia  and  thrombosis  of  cavernous  sinus. 

S.  E.  Allen,  Cincinnati.  B. — Two  cases  following  operation 
for  acute  mastoiditis.  Both  severe — inflammation  extending 
over  entire  head.  After  recovery  mastoid  wounds  healed  with 
marked  rapidity. 

D.  T.  Vail,  Cincinnati.  A. — One  case  pansinusitis,  right. 
Recurrent  attacks  of  erysipelas.  Finally  carcinoma  of  right 
upper  jaw.  B. — Boy,  aged  11.  Operation  for  acute  mastoidi- 
tis. Severe  erysipelas.  T.  105  F.  for  10  days.  Great  pain. 
Endocarditis.     Recovery. 

E.  E.  Mather,  Akron.  A. — One  case.  Nose  had  been 
squeezed.  Abscess  of  cartilaginous  septum  resulted.  Facial 
erysipelas.  T.  104  F.  Recovery.  B. — Babe,  10  months  old. 
Aucute  mastoiditis.  Erysipelas  developed  within  twenty-four 
hours  after  operation  and  ran  a  severe  course.     Recovery. 

J.  Walter  Park,  Harrisburg.  A.- — Woman,  aged  43  years. 
In  the  past  fifteen  years  has  had  three  attacks  of  facial  ery- 
sipelas always  following  a  severe  coryza.  Would  generally 
come  on  after  resolution  had  set  in  when  she  was  blowing  a 
profuse  purulent  discharge  from  the  nose.  There  is  no  sinus 
disease. 

W.  G.  Craig,  Springfield,  Mass.  B. — Case  I. — Nurse,  aged 
26.  Ot.  med.  pur.  ac.  post-tonsillitis.  Operated  upon  in 
hospital.  Erysipelas  on  fourth  day,  side  of  face  and  neck. 
Mild  attack.  Recovery.  Case  II. — Woman,  aged  65.  Acute 
mastoiditis  following  la  grippe.  Lived  five  miles  in  country. 
Operated  upon  at  home.  Erysipelas  very  severe  fourth  day. 
Unable  to  account  for  infection.  Neither  family  physician, 
nurse  nor  Craig  had  seen  or  attended  a  case  of  erysipelas  for 
six  months.     Recovery  slow  but  perfect. 

J.  A.  Stucky,  Lexington,  Ky.  B. — Four  cases.  Females  be- 
tween 30  and  60  years  of  age.  Operation  for  chronic  mastoidi- 
tis. B. — Three  cases  following  operations  for  extensive  sup- 
puration with  great  destruction  of  bone — all  were  females. 
While  temperature  was  high,  104-105  F.,  all  recovered.  G. — • 
Woman,  aged  41.  Cause  attributed  to  overlooked  infected 
ethmoid  cell  which  infected  operative  area  on  fourth  day. 
Severe  attack.    Recovery. 

Cornelius  G.  Coakley — New  York.  "I  have  had  it  (erysipe- 
las)  in  frontal  sinus  cases  and  have  had  it  in  mastoid  cases, 


ETiOIvOGY  OF  ERYSIP:eLAS.  41 

and  I  also  believe  that  the  lack  of  resisting  power  of  the 
patient  has  considerable  to  do  with  any  individual  case." 

Robert  Sattler,  Cincinnati.  B. — Operation  for  chronic 
mastoid  inflammation.  Woman,  aged  40.  Erysipelas  of  face 
and  neck  developed  five  days  after  operation.  Recovery. 
(Hospital  case.)  C. — Extensive  disease  of  anterior  ethmoidal 
cells,  middle  and  lower  turbinal  associated  with  blenorrhea  of 
tear  sac.  Operation  on  tear  sac  and  nasal  duct  followed  by 
erysipelas  of  face  and  scalp.  Two  subsequent  attacks  without 
surgical  interference  since  then.  In  good  health  now  but  has 
a  purulent  discharge  from  the  nose  and  some  discharge  from 
sac.  C. — ^One  case  of  extensive  epithelial  carcinoma  of  the 
orbit  invading  also  the  frontal,  ethmoidal  and  maxillary  sinuses. 
On  the  sixth  day  following  surgical  intervention,  erysipelas  of 
face,  scalp  and  neck.  Death  one  and  one-half  year  afterward 
from  erosion  of  the  dura.  Operation  performed  at  home  of 
patient. 

Victor  Ray,  Cincinnati.  B. — Operation  for  acute  mastoiditis. 
Woman  in  bad  condition  when  she  entered  hospital.  Violent 
attack,  but  recovery  without  serious  damage. 

Geo.  P.  Marquis,  Chicago.  A. — One  case  of  erysipelas  com- 
plicating an  otitis  media. 

Huntington  Richards,  St.  Paul's  School,  Concord.  A. — 
Erysipelas  in  course  of  chronic  mastoid  disease  in  small  negro 
child  seen  at  Vanderbilt  Clinic,  N.  Y.,  about  fifteen  years  ago. 
Severe  attack.    Recovery. 

Jas.  F.  McKernon,  New  York.  B. — Four  cases  erysipelas 
after  operation  for  acute  mastoid  disease. 

1st  case  developed  24  hours  after  operation. 

2nd  case  developed  12  hours  after  operation. 

3rd  case  developed  2  days  after  operation. 

4th  case  developed  3  days  after  operation. 

All  adults.  All  were  clinic  cases.  Three  of  them  neglected 
cases  and  the  disease  had  progressed  for  weeks. 

L.  R.  Culberston,  Zanesville.  A. — Eight  cases  mild  facial 
erysipelas  resulting  from  dacryocystitis  due  to  nasal  infection 
of  sac,  in  all  probability.  Recovery  without  lesions  in  all  but 
one  case.  B. — 1.  Child  of  6  years.  Erysipelas  following 
operation  for  acute  mastoiditis.  2.  Man  of  62  years.  Alco- 
holic. Erysipelas  after  operation  for  acute  mastoiditis.  Severe 
case.     Death. 

Geo.  B.  McAuliflfe,  New  York.     C. — Erysipelas  following 


42  ETIOLOGY  OF  ERYSIPELAS. 

removal  of  ecchondrosis  near  the  vestibule  on  right  side.  Ery- 
sipelas was  mild  and  only  spread  over  part  of  face.  Appeared 
two  days  after  operation  and  lasted  four  days.  Operation  was 
aseptic  and  infection  was  apparently  independent  of  the  pro- 
cedure. 

J".  F.  Klinedinst,  York,  Pa.  B. — Man,  aged  30.  Pain  in  ear 
four  days,  followed  by  puro-sanguinolent  discharge.  Profuse 
discharge  of  pus.  Auricle  covered  with  a  number  of  small 
pustules,  red  and  swollen.  Mastoiditis.  Operation.  Pus  in 
antrum,  no  disease  of  bone.  In  twenty-four  hours  erysipelas 
developed  in  neighborhood  of  ear.  Extended  to  mastoid  wound 
and  opposite  side  of  face.  Unusual  aseptic  care  in  operative 
measures.    Infection  probably  present  at  time  of  operation. 

J.  M.  Ray,  Louisville.  A. — Two  cases  of  empyema  of  the 
antrum  of  Highmore.  Had  been  operated  upon  and  the  opera- 
tion wound  had  healed  and  the  patients  were  wearing  tubes 
in  the  canine  fossae.  One  case  of  erysipelas  came  on  several 
weeks  after  operation,  the  other  case  six  or  eight  months.  In- 
flammatory process  started  about  the  nose  and  inner  angle  of 
the  eyes.  B. — No  personal  experience  with  acute  disease,  but 
when  a  hospital  interne  saw  two  or  three  cases  develop  after 
operations  for  acute  mastoiditis.  One  case  following  a  radical 
operation  for  chronic  disease.  Inflammation  started  around 
the  ear,  but  got  well  promptly  without  infecting  the  wound. 
Incision  healed  per  priman. 

Chevalier  Jackson,  Pittsburg.  A. — Man,  aged  27.  Three 
attacks  of  facial  erysipelas,  starting  on  bridge  of  nose,  left  of 
median  line.  No  attack  to  date  since  curettage  of  necrosing 
ethmoiditis  three  years  ago.  A. — Man,  aged  40.  For  five 
years  had  semi-annual  attacks  of  facial  erysipelas  starting  in 
various  locations.  No  attack  for  two  years  since  radical  treat- 
ment of  pansinusitis.  F. — Fatal  facial  erysipelas  starting  under 
right  eye  and  extending  all  over  upper  face  and  scalp.  Com- 
mencing on  first  day  and  ending  on  fifth  day  after  evacuation 
of  sphenoidal  sinus,  in  a  man  28  years  of  age. 

W.  K.  Butler,  Washington,  D.  C.  A. — Following  operation 
for  acute  disease,  facial  erysipelas  developed  extending  to 
but  not  involving  wound.  Recovery.  Private  patient  in  private 
room  in  hospital.     No  history  of  contagion  could  be  traced. 

H.  M.  Fish,  Chicago.  A: — Case  I. — Young  woman.  Brawny 
swelling  of  left  orbital  region — lids,  cheek,  root  of  nose — that 
made  it  nearly  impossible  to  open  the  eye.   The  condition  was 


ETIOI^OGY  .OF  ERYSIPEI^AS.  43 

diagnosed  erysipelas  by  a  physician.  Pain  over  frontal  sinus. 
Fundus  normal.  No  exophthalmos  or  ophthalmoplegia. 
Syringing  a  mucopurulent  secretion  from  the  frontal  sinus 
restored  conditions  to  normal  in  a  few  days.  A.— Case  II. — 
A  woman  came  with  left  facial  erysipelas  that  appeared  two 
days  before.  Lids  greatly  swollen— <:ould  not  be  opened. 
Marked  tense  edema  of  supraorbital  region  and  root  of  nose. 
Lower  lid  and  cheek  raised  almost  to  level  of  ridge  of  nose. 
Skin  tense,  glistening ;  blebs.  No  ocular  involvement.  Syring- 
ing the  sinuses.  Restoration  to  normal  in  five  days.  C.~Case 
m- — "Several  years  ago  while  in  Vienna  I  removed  some 
large  polypi,  the  nostril  being  acutely  and  markedly  congested. 
I  plugged  the  nostril  and  the  following  day  there  was  an 
erysipelas  of  the  root  of  the  nose,  cheek  and  hds  of  correspond- 
ing side.  The  plugs  were  removed,  revealing  a  free  flow  of 
pus.    The  patient  was  not  seen  again. 

J.  W.  Murphy,  Cincinnati.  G.—Case  /.—Man,  aged  26. 
Operated  on  for  chronic  empyema  right  frontal  sinus  and 
antrum.  Five  days  later  erysipelas  involving  entire  head. 
B. — Case  II. — Girl,  aged  2.  Operation  for  acute  mastoiditis. 
Five  days  later  erysipelas  developed  in  wound. 

T.  Passmore  Berens,  New  York.,  ^.— "I  have  had  but  one 
case  of  facial  erysipelas  which  could  be  attributed  with  more 
or  less  positiveness  to  the  nose.    This  case  was  one  of  chronjc 
ethmoiditis  of  the  anterior  cells  complicated  with  a  general 
atrophic  (ozoenatous)  rhinitis.     This  particular  case  had  four 
attacks  of  facial  erysipelas,  one  attack  starting  in  the  inner 
canthus  of  one  eye  and  the  three  other  attacks  starting  in  a 
fissure  in  the  vestibule  of  the  nose.     These  attacks  occurred 
some  ten  or  twelve  years  ago.    The  patient  has  had  no  attacks 
for  more  than  eight  years.  The  treatment  of  the  ethmoid  has  re- 
sulted in  a  cure  of  his  nasal  condition,  excepting,  of  course, 
that  the  membranes  are  still  atrophied."    B. — "In  the  last  four 
or  five  years  I  have  seen  certainly  six  cases  that  I  can  recall 
(and  there  was  probably  more)  in  which  facial  erysipelas  of  a 
severe  type  developed  following  operation  for  acute  mastoid 
disease.     These  cases  included  both  hospital  and  private  prac- 
tice.   It  may  be  not  unwise  to  state  that  the  operations  were  all 
performed  under  rigid  asepsis.     All   of  the  cases  mentioned 
recovered  without  serious  injury  resulting." 

J.  HoHnger,  Chicago.     ^.— One  case  of  erysipelas  due  to 
acute  suppuration  of  the  ear.    B. — One  case  of  erysipelas  fol- 


44  ETIOLOGY  OF  ERYSIPELAS. 

lowing  the  radical  operation  for  chronic  mastoiditis.  The 
erysipelas  spread  over  the  back  and  a  large  part  of  the  body 
and  the  patient  died. 

Unsigned  communication  from  some  member  of  the  Ameri- 
can Laryngological  Society,  the  American  Otoiogical  Society, 
the  American  Academy  of  Ophthalmology  and  Oto-Laryngol- 
ogy,  and  the  American  Ophthalmological  Society.  B. — • 
Woman,  aged  56.  Erysipelas  following  upon  operation  for 
acute  mastoiditis  in  a  small,  dirty  house.  Recovery.  B. — 
Erysipelas  following  upon  operation  for  acute  mastoid  disease 
in  hospital. 

Chas.  M.  Robertson,  Chicago.  B. — "Woman,  aged  27. 
Chronic  suppurative  otitis  media  since  12  years  of  age.  Right 
ear  operated  on  for  radical  mastoid  Feb.  14th,  1905.  Packed 
wo'und  with  iodoform  strips.  Following  day  iodoform  der- 
matitis seen  on  pinna.  Gauze  removed  and  plain  sterile  gauze 
used.  Erysipelas  began  in  two  days,  extending  over  face  to 
median  line.  Streptococcus  infection  in  right  leg,  knee  and 
ankle  joint.  Given  serum  twice  daily  for  ten  days.  Drained 
leg  and  knee  joint  by  aspiration  of  joint  and  free  incisions  m 
leg,  separating  muscles  and  washing  out  with  salt  water. 
Recovery  'of  face  in  11  or  14  days.  Knee  stiff  as  result. 
Broken  up  one  year  after,  but  no  permanent  result." 

•  J.  E.  Gleason,  Detroit.  A. — "Man,  aged  58.  Had  erysipelas 
five  or  six  times  at  varying  intervals.  Was  operated  upon 
for  chronic  suppuration  antrum  of  Highmore  nearly  two  years 
ago.  No  attack  of  erysipelas  since.  B. — Woman,  44  years. 
Culture  taken  from  ear  at  time  of  paracentesis  made  a  few 
hours  after  first  symptoms  appeared  showed  streptococcic  in- 
fection. Operation  for  acute  mastoid  disease  six  days  after 
paracentesis.  I  would  differentiate  between  erysipelas  and 
sterptococcic  skin  infection  clinically.  This  case  was  of  the 
latter  variety." 

W.  A.  Dietrich,  Chattanooga.  C. — Removed  a  septal  spur 
from  a  saloonkeeper.  Erysipelas  three  days  later.  Patient  was 
a  hard  drinker — from  1  pint  to  1  quart  of  whiskey  a  day.  Re- 
covery. Nine  months  later  removed  middle  turbinated  from 
same  patient  without  ill  results. 

A.  B.  Thrasher,  Cincinnati.  A. — Woman,  aged  30.  Tume- 
faction inferior  turbinate.  Used  galvano-cautery.  In  a  few 
days  facial  erysipelas.  Recovery.  The  patient  had  had  a 
previous  attack  of  facial  erysipelas  of  unknown  origin.    There 


ETIOI^OGY  OF  ERYSIPELAS.  45 

was  a  possible  involvement  of  anterior  ethmoidal  cells.     B. 

Erysipelas  three  weeks  after  opening  mastoid  antrum  for 
acute  mastoiditis  while  the  patient  was  apparently  doing  well. 
Patient  made  a  good  recovery  and  the  healing  of  the  mastoid 
wound  did  not  appear  to  be  much  hindered. 

J.  A.  Thompson,  Cincinnati.  ^.— Four  cases  of  primary 
erysipelas  of  nose  and  throat.  Condition  of  sinuses  not  de- 
termmed.  5.— One  case  erysipelas  following  upon  radical 
operation  on  an  ear  that  had  suppurated  for  twenty-seven 
years  in  which  the  external  wound  was  closed  at  the  time  of 
operation.  Recovery.  C— Erysipelas  of  face  and  scalp  after 
removal  of  septal  spur.  Patient  a  syphilitic  irailroad  man  who 
had  had  erysipelas  every  time  he  was  injured.  D. — Brewery 
collector  in  bad  physical  condition 'from  drink.  Erysipelas  of 
face,  neck  and  scalp  following  operation  upon  ethmoid  cells. 
Recovery. 

E.  Fletcher  Ingals,  Chicago.  C— "Just  one  case  in  which 
facial  erysipelas  twice  followed  the  use  of  menthol— about  gr. 
V  to  one  ounce  of  liquid  albolene." 

John  H.  Kincaid,  Knoxville.  Man,  aged  42.  Acute  eth- 
moiditis  right  and  left.  Erysipelas  beginning  at  the  orifice 
of  both  nasal  fossae.  In  twenty-four  hours  had  involved  sur- 
face of  nose,  cheeks,  forehead  and  ear.  "There  was  no  doubt 
in  my  mind  but  that  the  erysipelas  could  be  directly  traced  to 
the  ethmoidal  disease." 

James  B.   Clemens,   New  York.     5.— Following  operation 
for  acute  mastoid  disease.     "In  one  case  out  of  about  250 
operations.    Usual  acute  symptoms  and  local  conditions  in  girl 
of  19  years.     Erysipelas  developed  about  fifth  day,  two  days 
after  the  first  mastoid  dressing.    It  ran  an  uneventful  course." 
Jonathan  Wright,  New  York.     ^. —Three  cases  erysipelas 
starting  over  the  bridge  of  the  nose.     Were  practically  all  due 
to  nasal  infection  or  rather  post-nasal,  which  regularly  hold«: 
the    streptococcus    awaiting    a    favorable    systemic    condition 
C- — ^One  case  of  erysipelas  following  upon  nasal  operation  in 
a  case  of  chronic  nasopharyngitis. 

James  E.  Newcomb,  New  York.  A. — Has  "seen  two  or 
three  cases  of  erysipelas  due  to  infection  from  abrasions  in  the 
nasal  vestibule." 

C.^  F.  Theisen,  Albany.  ^._"One  case  of  recurring  facial 
erysipelas  complicating  a  chronic  empyema  of  the  frontal  sinus. 
Woman  about  45  years  of  age.     I  have  no  doubt  but  that  in 


46  ETIOLOGY  OF  ERYSIPELAS. 

this  case  the  frontal  sinusitis  was  the  etiological  factor  in  the 
facial  erysipelas."  C. — One  case  following  a  cauterization  of 
the  inferior  turbinate  in  a  young  lady.     No  sinus  disease. 

J.  S.  Prout,  Brooklyn.  A. — Facial  erysipelas  which  seemed 
to  result  from  a  leech  bite  in  acute  middle  ear  inflammation. 
No  mastoid  involvement." 

Allen  Greenwood,  Boston.  A. — "One  case  of  facial  ery- 
sipelas following  acute  disease  of  frontal  sinus.  After  re- 
oo'very  from  the  erysipelas  the  frontal  sinus"  was  obliterated  by 
operation." 

H.  Bert  Ellis,  Los  Angeles.  A. — Sailor,  aged  54  years. 
Under  treatment  for  dacryocystitis  exchronic  hypertrophic 
rhinitis.  Erysipelas  developed  left  side  of  face  about  left  eye. 
Severe  case.  Panophthalmitis.  Antistreptococcus  serum. 
(See  also  ocular •  complications  of  facial  erysipelas.)  A. — 
Man,  aged  25.  Hypertrophic  pharyngeal  catarrh.  Long  nar- 
row strip  of  mucous  surface  raw  and  covered  with  secretion. 
Application  AgNo  3.  In  twenty-four  hours  condition  im- 
proved. Twenty-four  hours  later  facial  erysipelas.  Recovery. 
B. — Woman,  aged  26.  Acute  rhinitis.  Acute  otitis  media  sup- 
purativa. Strepococci  in  both  nasal  and  ear  secretions.  Opera- 
tion. Patient  did  well.  Three  weeks  later  erysipelas.  Severe 
case.  "The  erysipelas  most  complete  involvement  of  the  entire 
body  I  have  ever  seen."  Antistreptococcus  serum.  Recovery. 
Wm.  E.  Gamble,  Chicago.  5.— Man,  aged  58.  Dec.  18th, 
1906,  removal  of  inspissated  cerumen  by  family  physician. 
Three  days  later  Gamble  found  otitis  media  suppurativa,  with 
perforation  M.  T.  Five  days  later  mastoiditis.  Operation. 
For  two  days  high  and  irregular  temperature.  Then  erysipelas 
developed  over  nose  and  cheeks.  Jan.  8th,  1907,  leucocytosis 
23,400.  Jan.  12th,  leucocytes  6,800.  Gamble  explains :  "Sud- 
den rise  of  temperature  with  pronounced  rigors  and  cyanosis 
and  extreme  leucocytosis  as  due  to  streptococci  entering  the 
blood  in  numbers  not  sufficient  to  overpower  the  leucocytes, 
being  themselves  overpowered." 

H.  B.  Gratiot,  Dubuque.  A. — -Two  cases  of  erysipelas  oc- 
curring in  connection  with  acute  otitis  media,  but  not  following 
operations. 

L.  L-  Doane,  Butler,  Pa.  A. — "Female,  married,  aged  40. 
Hypertrophic  rhinitis.  Subject  to  attacks  subacute  bronchitis, 
also  to  Assuring  left  ala  nasi.  Erysipelas  began  near  left  inner 
canthus   (might  have  begun  at  nose).     Severe  attack.     Re- 


ETIOLOGY  OF  ERYSIPELAS.  47 

covery.  C. — Male,  clerk,  aged  20.  Saw  operation  for  re- 
moval of  septal  spur.  Much  hemorrhage.  Plugged  posteriorly. 
Two  days  later  mild  'attack  facial  erysipelas. 

F.  L.  Waite,  Hartford.  B. — "Two  cases  of  erysipelas  ap- 
pearing on  the  third  day  after  operation — one  very  severe. 
Both  males.     Good  recovery." 

K.  K.  Wheelock,  Fort  Wayne.  B. — Medical  student,  aged 
23.  Double  mastoiditis  post-influenza.  Double  operation  in 
comparatively  new  and  excellent  hospital.  Three  days  later 
rise  in  T.  to  104.8  F.,  followed  by  erysipelas  appearing  over 
left  malar  bone.  Erysipelas  spread  widely  but  did  not  attack 
wounds.  Severe  case.  "I  attributed  the  site  of  infection  to 
be  the  nasal  cavity."  B. — Woman,  aged  64.  Chronic  abscess 
upper  inner  angle  of  orbit.  Necrosis  ethmoid  cells.  Following 
operation  patient  had  a  mild  attack  of  erysipelas. 

John  M.  Ingersoll,  Cleveland.  A. — "One  case  of  repeated 
attacks  of  facial  erysipelas  in  a  woman  who  had  nasal  polypi 
for  a  number  of  years  and  an  infection  of  both  antra,  both 
frontals  and  all  of  the  ethmoidal  sinuses.  The  removal  of  the 
polypi  and  the  treatment  of  the  sinuses  stopped  entirely  the 
attacks  of  facial  erysipelas.  A. — Attacks  of  facial  erysipelas 
in  a  man  who  had  an  infection  in  the  right  maxillary  and  the 
frontal  sinuses.  Treatment  of  the  sinuses  cured  both  condi- 
tions. A. — Two  cases  of  repeated  attacks  of  facial  erysipelas 
in  atrophic  rhinitis  without  involvement  of  the  sinuses.  Both 
cases  were  cured  of  erysipelas  and  the  nasal  condition  im- 
proved by  treatment.  D. — Operation  for  chronic  maxillary 
sinus  infection  followed  by  erysipelas.  Cultures  from  the 
antrum  gave  almost  pure  streptococci.  The  attacks  of  ery- 
sipelas complicated  matters  somewhat,  but  the  patient  recovered 
completely  from  both  conditions." 

J.  H.  Bryan,  Washington.  A. — One  case  of  facial  erysipelas 
occurring  in  a  case  of  syphilis  of  the  nose,  the  case  being  one 
of  extensive  necrosis  of  the  nasal  septum.  The  inflammation 
starting  within  the  nose  extended  to  the  outer  surface  and 
became  general  over  face  and  scalp.  B. — One  case  following 
operation  for  acute  suppurating  mastoiditis  occurring  on  the 
second  day.  The  inflammation  became  general,  affecting  the 
face  and  scalp.  A. — One  case  occurring  in  the  course  of 
chronic  disease  of  the  frontal  sinus.  Owing  to  a  relapse  fol- 
lowing the  first  operation  on  the  sinus  the  cavity  had  to  be 
reopened  and  was  treated  by  the  open  method.     In  conse- 


48  ETIOLOGY  OF  ERYSIPELAS. 

quence  of  patient  having  to  spend  some  time  on  railroad  trains 
the  wound  became  infected.  The  inflammation  extended  from 
the  sinus  wound  and  involved  the  whole  face  and  scalp. 

John  Clarence  Blake,  Boston.  B. — Cases  of  erysipelas 
"originating  apparently  apart  from  the  mastoid  wound,  as  in 
one  instance  on  the  vertex  in  a  case  in  which  the  mastoid 
wound  healed  by  first  intention  without  subsequent  disturb- 
ance, and  in  others  in  which  the  starting  point  of  the  local 
symptoms  was  on  the  face." 

Henry  L,.  Swain,  New  Haven.  C. — Erysipelas  following 
cauterization  (of  the  nose)  in  a  man  of  67.  C. — Erysipelas 
following  the  removal  of  an  exostosis  in  a  case  in  which  it  was 
discovered  that  there  was  a  concealed  or  latent  ethmoiditis, 
discharging  pus  from  an  anterior  cell.  5.— Six  or  eight  cases 
following  mastoid  operations.  All  hospital  cases  but  one.  This 
latter  had  the  disease  start  from  a  leech  bite  which  had  its 
bleeding  staunched  by  cotton  taken  from  the  wadding  of  an 
old  and  diseased  coat.  A. — '"Since  receiving  this  note  a  patient 
in  a  family  where  I  am  attending  an  acute  ear  case  has  de- 
veloped an  attack  of  erysipelas  which  apparently  commenced  in 
the  spot  on  her  nose  where  her  eyglasses  rest.  One  previous 
attack  three  years  ago." 

B.  Alex.  Randall,  Philadelphia.  A. — "Young  blacksmith  with 
acute  otitis  media  purulenta,  whose  canal  wall  posteriorly  had 
a  fistula.  Erysipelas  developed  without  operation."  A. — 
Erysipelas  developed  in  an  operated  cataract  case  although  her 
nose  had  been  gotten  into  decent  condition  previously  by  mild 
measures.  A. — Erysipelas  occurred  in  the  course  of  a  case  of 
otitis  media  purulenta. 

J.  Price  Brown,  Toronto,  Can.  C. — 'One  case  of  facial  ery- 
sipelas following  cutting  operation  upon  the  nasal  septum. 
Recovery.  C. — 'One  case  of  facial  erysipelas  following  electric 
cautery  operation  of  an  inferior  turbinal.  The  condition  for 
several  days  was  very  serious.  D. — One  .case  innumerable 
nasal  polypi  right  and  left.  Removal  very  freely  by  snares 
was  followed  two  days  later  by  erysipelas,  death  occurring  in 
one  week.  The  patient  had  been  greatly  exposed  to  cold  and 
wet  after  operation.  Family  physician  later  informed  Dr. 
Brown  that  the  patient's  father  died  after  an  operation  upon  the 
nose  of  a  similar  character  followed  by  erysipelas. 

E.  S.  Ferguson,  Oklahoma  City.  Doubtful  case.  A. — 
Septal  spur  on  right  side  impinging  upon  inferior  turbinal. 


ETIOLOGY  Oif  ERYSIPEIvAS.  49 

Removal.  Recovery.  Three  weeks  later  abrasion  of  helix  of 
ear.  Severe  erysipelas  developed  and  covered  two-thirds  of 
body. 

John  A.  Donavan,  Butte.  A. — Three  cases  in  men,  recently. 
All  had  had  previous  nasal  trouble.  Inflammation  of  sinuses 
not  determined  but  probably  present.  C. — One  case  erysipelas, 
woman  of  22,  following  removal  anterior  end  of  middle  turbi- 
nal.  C- — -Saw  one  case  erysipelas  follow  an  operation  on 
frontal  sinus  while  a  student  at  Ann  Arbor. 

Joseph  A.  Andrews,  Santa  Barbara.  A. — Young  man  while 
boxing  was  struck  on  nose.  Abrasions  but  no  fracture  of 
bones  could  be  detected.  A  few  days  later  erysipelas.  Orbital 
cellulitis.  Exophthalmos.  Death  in  a  few  days  of  meningitis. 
A. — Man,  aged  71.  Furuncle  external  auditory  canal.  Incised. 
Two  days  later  perichondritis  auriculae  and  erysipelas  of  face 
and  head.    Recovery. 

W.  Peyn  Porcher,  Charleston.  A. — ^Mastoiditis  in  an  old 
diabetic  subject  in  which  the  pus  worked  its  way  out  above  the 
zygomatic  process.  Erysipelas  followed.  Recovery.  B. — 
Erysipelas  following  a  secondary  mastoid  operation  affected 
the  whole  head,  but  did  not  involve  the  wound  itself.  Severe 
case.    Recovery. 

John  R.  Winslow,- Baltimore.  "Woman,  about  65.  Difficulty 
in  swallowing  due  to  paralysis  of  pharyngeal  constrictors. 
Velum  palati  unaffected.  History:  Severe  'cold'  followed  by 
membraneous  tonsillitis  and  middle  ear  infection;  subsequent- 
ly had  typical  outbreak  of  facial  erysipelas.  Streptococcus  in- 
fection." 

J.  Payson  Clark,  Boston.  C. — "One  case  of  marked  facial 
erysipelas  in  a  child  of  10  or  12  years,  following  immediately 
on  an  adenoid  operation.  Following  this  there  were  one  or 
two  other  cases  coming  on  after  operations  on  the  nose  or 
throat  at  the  same  clinic."  Antisepsis  for  the  rooms  and  tempo- 
rary abandonment  of  operations. 

Joseph  C.  Beck,  Chicago.  A. — "Four  cases,  all  in  women. 
All  had  fissures  at  external  nares  and  usually  at  the  menstrual 
period  an  edematous  surface  of  the  face  would  occur,  last  for 
a  few  days  and  then  disappear  again.  No,  or  very  little, 
temperature  and  if  fissures  were  healed  up  and  intransal  treat- 
ment instituted  (there  was  usually  some  malformation  present) 
patients  remained  well."  C. — Woman,  aged  43.  Complete 
filling  up  of  left  nostril  with  myxomatous  polypi.     Removed. 


50  ETIOLOGY  OF  ERYSIPELAS. 

Facial  erysipelas  followed  with  blebs.     Cultures  showed  strep- 
tococcus infection.     Recovery. 

F.  E.  Hopkins,  Springfield,  Mass.  A. — "Two  cases  of  facial 
erysipelas  secondary  to  infection  within  the  nose.  Both  were 
cases  of  atrophic  rhinitis  with  much  crusting  of  mucus  on 
the  septum.  The  septum  was  excoriated  from  the  frequent  re- 
moval of  the  crusts  and  with  each  removal  there  was  nearly 
always  more  or  less  bleeding.  In  both  cases  it  is  probable  that 
infection  was  conveyed  by  the  fingers.  The  first  patient  was  a 
gentleman  about  60,  a  literary  man,  the  second  a  housewife 
about  50."  B. — Marked  cellulitis,  following  mastoid  operation 
involving  half  the  surface  of  the  head.  Patient  a  child  of 
2^  years.  Marked  constitutional  symptoms.  T.  104  F.  Iodo- 
form gauze  was  the  initial  dressing.  The  cellulitis  promptly 
subsided  with  the  substitution  of  plain  sterile  gauze. 

Wendell  C.  Phillips,  New  York.  B. — Has  had  a  number  of 
cases  (cannot  remember  how  many  in  all)  following  mastoid 
operation  for  acute  disease.  "Three  during  the  present  winter, 
all  following  the  mastoid  operation  by  about  five  days.  All 
recovered."  In  chronic  disease  of  the  mastoid  "one  in  my 
service  at  Post-Graduate  Hospital  following  a  flap  operation. 
Recovery." 

Thos.  R.  Pooley,  New  York  (through  E.  H.  Gaudineer, 
House  Surgeon,  New  Amsterdam  Eye  &  Ear  Hospital).  B. — 
"(1)  Age  28.  Operated  for  acute  mastoiditis  June  5th.  Dis- 
charged to  return  for  dressings  June  29th.  Returned  July  8th 
with  erysipelas  facialis.  Treated  locally  and  constitutionally 
for  two  days  and  then  sent  to  Bellevue  Hospital.  (2)  Age  72. 
Otitis  media  purulenta  acuta  and  acute  mastoiditis.  Operated 
upon  Nov.  29th.  Sinus  exposed.  Next  day  edema  of  eyelids 
and  ocular  conjunctiva.  Dec.  1st,  erysipelas  facialis.  Wound 
dressed.  Treatment  local  and  general.  Dec.  2nd,  patient 
worse.  Mastoid  wound  and  sinus  infected.  Treatment  con- 
tinued. Wound  dressed  daily,  but  patient  continued  to  weaken. 
Dec.  13th,  patient  died  of  exhaustion,  septicemia  and  erysipelas 
following  mastoid  operation." 

G.  A.  Leland,  Boston.  A. — "Occasional  cases  of  facial  ery- 
sipelas where  port  of  entry  seemed  to  be  cracks  at  the  orifices 
of  the  nares,  ceasing  after  cracks  were  healed."  "Disease  of 
antrum  of  Highmore.  (1)  Male,  35  years.  Blow  (fracture?), 
right  superior  maxilla.  Redness  and  swelling  (erysipelas?) 
right  malar  region;   delirium  tremens;  discharge  from  nose. 


ETIOLOGY  OF  ERYSIPELAS.  ~  51 

Caldwell-Luc  operation.  Recovery.  (2)  Boy,  4  years.  Great 
redness  and  swelling  right  cheek.  Rhinitis  purulenta  (probably 
specific).  Operation  canine  fossa  (Janson)  K.  I.,  etc.  Re- 
covery." B. — Mastoid  operation  for  acute  disease.  •  "Several. 
Recovery  not  retarded  in  one.  Antistreptococcus  serum  seemed 
to  control  the  disease.  One  woman  of  45.  Erysipelas  followed 
in  few  days  after  operation  in  private  hospital.  Recovery  in 
public  hospital  to  which  she  was  sent.  Left  hospital  and  in 
a  week  or  so  was  back  with  second  attack  of  erysipelas.  Wound 
healing  about  as  usual."  Mastoid  operation  for  chronic  disease. 
"Several.  One  girl  19.  Antistreptococcus  serum  was  followed 
by  nearly  normal  temperature  in  about  twelve  hours."  Leland 
closes  his  report  with  the  following  comments :  "In  a  large 
municipal  hospital,  where  most  of  my  cases  are  treated,  attacks 
of  erysipelas  are  not  so  very  uncommon.  It  hasn't  seemed  to 
me  that  these  attacks  were  in  any  way  due  to  the  location  of 
the  operation  and  in  some  cases  the  erysipelas  may  develop  be- 
fore the  mastoiditis  necessitates  operation,  and  facial  erysipelas 
frequently  simulates  mastoiditis  when  behind  the  ear,  so  that 
occasionally  cases  are  sent  in  with  diagnosis  of  mastoiditis,  tor 
operation,  when  there  is  no  involvement  of  the  bone." 

Louis  J.  Goux,  Detroit.  A. — "One  case  of  facial  erysipelas 
which  I  believed  to  be  due  to  infection  through  .ulcerated  area 
on  septum  in  right  naris.  The  case  was  further  complicated 
by  an  acute  attack  of  double  otitis  media." 

Emil  Amberg,  Detroit.  A. — "A  very  severe  erysipelas  after 
or  accompanying  a  double  otitis  media  in  a  physician's  wife. 
I  thought  at  that  time  that  the  fact  that  chloroform 
was  administered  for  the  double  myringotomy  without  pro- 
testing the  skin  with  vaseline  might  have  been  responsible  to 
some  extent  for  the  complication." 

Chas.  W.  Richardson,  Washington.  B. — "The  only  cases 
of  erysipelas  I  have  had  are  in  connection  with  the  operation 
on  the  mastoid.  All  these  resulted  from  too  great  effort  in  the 
cleansing  of  the  mastoid  before  the  operative  intervention,  thus 
denuding  the  particular  surface  over  and  about  the  mastoid. 
The  flowing  of  the  bacteria-laden  pus  over  this  surface  gave 
■rise  to  the  erysipelas  which  ensued.  Since  I  have  ceased  the 
vigorous  cleansing  of  the  mastoid  I  have  had  no  cases  of  ery- 
sipelas, thus  apparently  proving  my  conjecture  as  to  the  cause." 

A.  Coolidge,  Jr.,  Boston.  A. — ^"I  have  for  some  time  looked 
upon  facial  erysipelas  starting  from  the  region  of  the  nose  as 


52  ETIOI,OGY   OF  ERYSIPELAS. 

due  to  intranasal  or  vestibular  infection,  although  often  no 
point  of  infection  within  the  nose  can  be  proven.  Without 
having  any  records  at  hand  I  should  say  that  in  many  cases  of 
facial  erysipelas  there  is  to  be  found  a  marked  septic  condition 
in  the  nasal  vestibule  or  vicinity.  C. — A  severe  facial  erysipelas 
developed  a  few  days  after  I  had  opened  a  foul  antrum  through 
the  inferior  meatus.  The  erysipelas  started  near  the  ala  on 
the  same  side." 

Chas.  J.  Kipp,  Newark.  A. — "I  have  had  a  number  of  cases 
of  otitis  media  purulenta  in  which  facial  erysipelas  developed 
while  there  was  otorrhea.  The  erysipelas  started  from  the 
external  meatus  and  traveled  over  the  face  and  neck."  B. — 
Cases  of  erysipelas  following  operation  for  acute  and  chronic 
mastoiditis.    Unable  to  give  numbers.    All  recovered. 

Hanau  W.  Loeb,  St.  Louis.  C. — A  patient  developed  ery- 
sipelas ten  days  after  a  spur  operation.  He  had  failed  to 
present  himself  regularly  for  observation.    Recovered. 

Walter  J.  Freeman,  Philadelphia.  A. — "In  my  hospital  ex- 
periences it  was  quite  common  to  have  patients  having  had 
frequent  attacks  of  erysipelas.  .  .  .  One  case  of  atrophic 
rhinitis  now  under  treatment  gives  a  history  of  repeated  at- 
tacks of  erysipelas  before  treatment  a  year  ago,  but  none 
since  then." 

F.  L.  Knight,  Boston.  C. — "The  only  case  of  facial  ery- 
sipelas I  remember  occurred  in  a  patient  during  an  acute  in- 
flammation in  the  antrum.  She  has  since  had  one  acute  ex- 
acerbation of  the  antrum  disease  (without  erysipelas),  which 
quietly  subsided,  she  declining  operation." 

Wm.  C.  Bane,  Denver.  A. — "Woman,  aged  34.  Tubercu- 
lous subject.  Acute  double  otitis  media  and  mastoiditis. 
Streptococcic.  Operation  on  right  mastoid  seventh  day.  Not 
much  involvement.  Erysipelas  third  day  after  operation. 
Pleurisy  fourth  day.  Death  seventh  day  after  operation. 
No  attempt  at  repair  in  wound." 

J.  E.  Sheppard,  Brooklyn.  B. — "A  considerable  number  of 
cases  of  erysipelas  following  mastoid  operation  for  acute  dis- 
ease. All  did  well  save  two — one,  a  diabetic,  mastoid  wound 
nearly  healed,  infected  by  general  practitioner  fresh  from  a 
case  of  puerperal  sepsis ;  died  finally  from  meningitis.  The 
second,  an  elderly  woman,  died  in  almshouse  after  leaving  my 
care." 

Francis  W.  Alter,  Toledo.     C. — "Recently,  I  resected  a  de- 


ETIOLOGY  OF  ERYS1PEI.AS.  53 

fleeted  septum  nasi  and  for  a  week  thereafter  patient  did  well, 
but  at  that  time  he  came  down  with  a  well-defined  attack  of 
erysipelas,  which  evidenced  itself  first  over  the  dorsum  of  the 
nose.  I  thought  at  first  that  he  was  in  for  an  abscess  because 
of  its  circumscribed  character,  but  soon  the  other  symptoms 
of  erysipelas  appeared.  .  ,  .  There  seemed  at  no  time  to 
be  any  retardation  of  the  healing  process."  After  a  week, 
recovery. 

John  W.  Farlow,  Boston  (in  addition  to  cases  cited  in  the 
text).  B. — Man,  70  years.  Nasal  polypi  and  polypoid  degene- 
ration in  right  ethmoid  region.  Removal  of  polypoid  tissue  with 
cold  snare;  considerable  bleeding;  gauze  packing;  marked 
facial  erysipelas  starting  on  same  side  of  nose  the  next  day. 
Recovery. 

Sargent  F.  Snow,  Syracuse.  C. — Two  cases,  one  private 
and  one  public  hospital,  in  which  erysipelas  followed  operation 
on  nasal  septum.  The  origin  of  erysipelas  in  private  case  un- 
known; of  the  hospital  case,  "was  clearly  from  the  infection 
that  existed  in  the  ward." 

Henry  Manning  Fish,  Chicago  (in  addition  to  previous  com- 
munication) :  "A  day  or  two  after  writing  you  I  was  allowed 
to  examine  a  patient  of  Dr.  J.  H.  Cook,  who  was  suffering 
from  facial  erysipelas  covering  the  entire  face,  head  and  ears. 
There  was  a  distinct  history  of  an  acute  right  tpaxillary  em- 
pyema four  years  before,  with  spontaneous  discharge  through 
the  nostrils.  About  ten  days  before  I  saw  the  patient,  follow- 
ing influenza,  she  had  another  attack  of  right  maxillary  em- 
pyema, intense  pain,  swelling  of  the  cheek,  etc.,  with  subsidence 
after  a  profuse  right  nasal  discharge.  A  few  days  later  ery- 
sipelas appeared  at  the  root  or  bridge  of  the  nose,  spreading 
therefrom  as  mentioned  above.  When  I  saw  the  patient  she 
was  desquamating  and  numerous  blisters  on  the  face  and 
scalp  had  dried  up;  the  fever  had  subsided  and  she  was  con- 
valescing. ...  I  took  one  culture  from  pus  on  the  floor 
of  the  nostril  and  a  second  one  from  pus  in  the  right  middle 
meatus.  Dr.  Gehrmann,  of  the  Columbus  Medical  Laboratory, 
reports  streptococcus  in  each  culture." 

Francis  R.  Packard,  Philadelphia.  A. — "I  have  seen  two 
cases  of  erysipelas  occurring  in  both  instances  in  adult  males, 
involving  the  side  of  the  face  and  originating  in  what  seemed 
to  be  a  furunculosis  of  the  nasal  vestibule.  B. — I  performed  a 
Schwartze-Stacke  operation  upon  an  Italian  at  the  Pennsyl- 


54  ETIOLOGY   OF  ERYSIPELAS. 

vania  Hospital  for  acute  mastoiditis  occurring  in  the  course  of 
typhoid  fever.  The  operation  was  performed  upon  the  thirty- 
second  day  of  the  disease.  Four  days  after  the  operation  ery- 
sipelas developed  on  the  side  of  the  head  on  which  the  opera- 
tion had  been  performed.  The  resident  in  charge  of  the  case 
had  been  directly  in  contact  with  several  cases  of  erysipelas 
occurring  in  the  hospital.  Boy,  aged  10.  Acute  otitis  media 
purulenta  left  ear.  Considerable  edema  below  left  mastoid. 
Mastoid  opened — porous  and  soft — large  central  cavity  con- 
taining pus.  Four  days  later  developed  erysipelas  in  neighbor- 
hood of  operative  wound.  Very  ill  for  four  days.  Mastoid 
wound  and  ear  completely  healed  in  four  weeks. 

Thos.  Hubbard,  Toledo.  A. — "Many  of  the  cases  of  facial 
erysipelas  that  I  have  seen  have  had  primary  or  secondary 
nasal  and  throat  manifestations.  In  a  few  the  primarily  in- 
fected area  was  an  excoriation  in  anterior  naris,  whence  it 
spread  to  deeper  regions  and  over  the  skin.  I  cannot  trace  any 
case  to  known  sinus  disease,  but  have  suspected  general  sinus 
infection  in  all  severe  cases  involving  nares  secondarily.  A 
recent  case  of  erysipelas  in  an  infant,  contracted  from  grand- 
parent who  had  subacute  or  chronic  type  of  facial  erysipelas, 
involved  throat,  nares,  face  and  scalp.  Had  to  amputate  uvula 
on  account  of  obstructed  respiration.  Streptolytic  serum  in 
large  and  repeated  doses  kept  the  youngster  alive  for  four  or 
five  days,  that  is,  temperature  would  drop  and  symptoms 
ameliorate  temporarily,  but  death  come  finally  from  exhaustion 
due  to  persistence  of  infection  and  relapses." 

Gordon  King,  New  Orleans.  C. — "Have  seen  one  case  due 
to  infection  of  nose  following  a  submucous  resection  of  septal 
cartilage  and  another  following  cauterization  of  the  inferior 
turbinal." 

B.  L.  Alillikin,  Cleveland.  A. — "Some  years  ago  I  had  a 
case  of  erysipelas  following  on  an  acute  attack  of  middle  ear 
abscess,  and  was  myself  infected  through  the  tear  duct  proba- 
bly and  the  antrum  of  Highmore,  but  not  after  any  operative 
procedure." 

G.  W.  Spohn,  Elkhart,  Ind.  A. — Has  had  cases  of  facial 
erysipelas  which  he  considers  due  to  disease  of  the  nose  or 
its  accessory  sinuses. 

A.  R.  Amos,  Des  Moines.  C. — "One  case  developed  erysip- 
elas following  removal  of  middle  turbinate  with  scissors  and 
snare.  It  recovered  after  a  general  facial  erysipelas  of  the 
same  side." 


ETIOLOGY  OF  ERYSIPELAS.  55 

Harris  G.  Sherman,  Cleveland.  C. — Woman,  aged  34. 
After  galvano-cauterization  of  the  inferior  turbinate  a  violent 
erysipelas  ensued,  involving  entire  bead;  extended  over  body. 
Death  four  weeks  after  operation. 

W.  Scott  Renner,  Buffalo.  B. — Mastoid,  acute  disease. 
"Developed  erysipelas  three  days  after  operation.  Complete 
recovery  with  no  loss  of  hearing."  Mastoid,  chronic  disease. 
"Patient  facial  paralysis  twelve  hours  after  operation  and 
facial  erysipelas.  Complete  recovery  from  paralysis  and  ery- 
sipelas. Chronic  discharge  cured."  C. — "Erysipelas  developed 
after  the  removal  of  hypertrophied  tissue  on  the  lower  turbi- 
nated bone.  Uninterrupted  recovery.  This  patient  has  had 
previous  and  subsequent  attacks  of  erysipelas."  B. — "Patient 
has  ethmoiditis,  maxillary  sinusitis  and  nasal  polypi.  The  ery- 
sipelas developed  after  removing  polypi.  Ran  uninterrupted 
course  to  recovery. 

Arnold  Knapp,  New  York  (in  addition  to  cases  cited  in  the 
text).  Pansinusitis.  Severe  and  finally  fatal  case.  After  the 
first  operation,  attacking  the  right  ethmoid  cells  and  frontal 
sinus,  erysipelas  appeared  at  once  with  a  T.  104  F.  While 
this  condition  persisted,  although  the  symptoms  of  sinusitis  of 
the  left  ethmoid  and  frontal  were  urgent,  it  was  thought  best 
to  defer  opening  these  cavities.  The  operation  on  the  left  side 
was  not  undertaken  for  a  month  after  that  on  the  right. 
Osteomyelitis  of  the  bones  of  the  skull  and-  face  set  in  (a 
streptococcic  infection  of  a  low  grade  intensity),  extended  to 
the  squamous  portion  of  the  right  temporal  bone,  causing  an 
epidural  abscess  with  thrombosis  of  the  sigmoid  sinus,  pyemia 
and,  notwithstanding  active  surgical  measures  wherever  pus 
was  suspected,  finally  caused  the  death  of  the  patient.  (Re- 
ported in  Archives  of  Otology,  Vol.  XXXII,  No.  3,  1903.) 
B. — Two  cases  of  erysipelas  following  on  operations  for  acute 
mastoiditis.  One  case  of  erysipelas  following  on  operation  for 
chronic  mastoiditis. 

H.  A.  Alderton,  Brooklyn.  B. — A  number  of  cases  of  ery- 
sipelas following  operation  for  acute  mastoid  disease.  A. — 
"Have  just  done  one  operation  on  a  case  in  which  the  erysipelas 
preceded  the  operative  attack;  sequence,  the  grip,  ear  pain 
for  one  week,  rupture,  seen  by  me  for  first  time,  erysipelas 
next  day,  treatment  of  erysipelas  for  a  week  or  one  and  a  half 
weeks,  operation  showed  great  destruction  but  intact  inner 
table.     Recovery."     B. — A  number  of  cases  following  opera- 


56  ETIOLOGY  OI^  ERYSIPELAS. 

tion  for  chronic  mastoid  disease,  "though  I  think  only  in  acute 
exacerbations  oi  the  chronic  trouble  and  mostly  associated  with 
dermatitis  of  the  canal.  All  my  cases  have  recovered  even 
when  the  dura  was  exposed." 

Arthur  B.  Duel,  New  York.  B. — After  operation  acute 
mastoid  disease.  "Three  cases  in  clinic.  Facial  erysipelas. 
All  recovered.  Two  cases  in  private  practice.  Facial  ery- 
sipelas. Both  recovered."  After  operation,  chronic  mastoid 
disease.  "Two  cases  in  clinic.  Recovered.  One  in  private 
practice.  Extensive,  whole  of  head,  chest  and  back.  Desper- 
ately ill.     Recovered." 

Having  thus  reviewed  the  facts  at  some  length  and  noted 
the  theories  put  forth  by  various  observers,  both  American 
and  Continental,  let  us  see  to  what  conclusions  these  facts, 
more  or  less  illuminated  by  these  theories,  will  certainly  and 
unavoidably  lead  us. 

First. — 'The  identity  of  the  streptococcus  as  the  contagium 
vivtim  or  microbial  cause  of  erysipelas  is  a  fact  of  such  uni- 
versal knowledge  as  to  call  for  but  formal  mention.  It  is 
necessary,  however,  to  call  attention  to  a  few  of  its  characteris- 
tics. It  is  of  slow  growth  and  of  variable  morphology  when 
its  environment  is  changed.  Its  pathogenicity  is  also  a  matter 
of  variability.  It  is  probably  but  rarely  air  borne,  needing 
direct  personal  contact  in  the  vast  majority  of  instances  for 
its  transference,  so  that  Ohlmacher  speaks  of  their  "well  ad- 
vanced adaptation  to  parasitism." 

Second. — We  note  the  practically  constant  presence  of  the 
streptococcus  and  the  pneumococcus  in  the  normal  nose  and 
neighboring  spaces,  such  as  the  throat  and  the  mouth,  and 
possibly  the  normal  accessory  cavities  and  the  ear.  The  ob- 
servations bearing  on  this  fact  I  have  taken  care  to  give  you  in 
great  detail. 

Third. — We  recognize  the  great  variability  in  pathogenicity 
of  both  the  streptococcus  and  the  pneumococcus.  Both,  as  we 
know,  lie  latent  for  months,  for  years,  and  even  for  an  entire 
human  lifetime,  may  bring  forth  absolutely  countless  millions 
of  generations  upon  the  hospitable  pituitary  mucous  membranes 
of  their  host  without  betraying  by  a  single  overt  act  their 
presence.  But  this  quiet  and  indolent  existence  may  be  broken 
in  upon  at  any  moment.  Man  has  again  and  again  produced 
this  disturbance  and  roused  these  cocci  to  virulent  fury  under 
laboratory  conditions,   and  nature  has   produced  these   same 


ETIOLOGY  OF  ERYSIPELAS.  57 

storms  in  the  human  host  of  the  streptococcus  and  the  pneumo- 
coccus  either  (a)  by  temporarily  and  through  some  unknown 
cause  inducing  virulence  in  the  microorganisms,  or  (b)  through 
some  unfavorable  conditions  which  profoundly  affect  the 
patients  and  alter  the  constitution  of  the  fluids  and  probably 
also  the  solids  of  the  body,  thereby  supplying  that  environment 
which  is  necessary  to  induce  the  change  which  we  call  virulence, 
which  consists  essentially  in  a  tremendous  stimulation  of  the 
reproductive  energies  of  the  cocci  with  an  attendant  formation 
of  toxins. 

Fourth. — This  process  just  referred  to  is  not  an  unusual 
one  in  microbial  pathology.  We  are  familiar  with  practically 
the  same  phenomena  in  the  life  history  of  the  typhoid  bacillus 
and  the  baccilus  tuberculosis. 

fifth. — The  extreme  frequency  of  erysipelas  upon  the  face, 
as  compared  with  its  invasion  of  other  parts  of  the  body,  has 
been  noted  for  centuries.  Only  recently  has  the  discovery 
that  the  cavities  of  the  bones  of  the  face — indeed,  that  the 
whole  upper  air  tract — is  the  normal  habitat  of  the  microbial 
cause  of  erysipelas  furnished  us  with  a  rational  explanation 
of  this  predilection,  and  I  have  no  doubt  that,  now  that 
the  attention  of  the  general  physician  and  surgeon  is  called  to 
this  matter  by  the  rhinologist,  w^  will  find  that  many  mysterious 
outbreaks  of  erysipelas  or  other  streptococcus  infection  will 
be  traced  to  some  diseased  nasal  passage  among  the  entourage 
of  the  patient.  I  have  in  mind  the  case  of  a  distinguished 
Philadelphia  obstetrician  (communicated  to  me  by  one  who 
was  acquainted  with  the  last  generation  of  Philadelphia  physi- 
cians) who  in  the  latter  years  of  his  life  left  behind  him  a 
trail  of  puerperal  sepsis  which  counted  some  90  or  100  cases 
and  which  was  attributed  by  his  colleagues  to  the  fact  that 
he  was  afflicted  with  a  chronic  ozena. 

Sixth. — I  have  cited  to  you  a  large  number  of  spontaneous 
cases  and  surgical  accidents  occurring  under  the  observation 
of  a  very  small  proportion  of  trained  and  educated  men  who 
make  up  our  great  American  medical  profession.  These  cases 
and  accidents  are  just  such  as  one  would  expect  to  occur  in  a 
certain  proportion  of  patients  under  these  known  conditions. 
It  must  be  a  fact  that  modern  aseptic  and  antiseptic  methods 
has  reduced  the  number  of  these  infections  where  the  virulence 
of  the  cocci  has  been  mild,  but  the  anatomical  arrangement  of 
the  parts  and  the  fact  that  virulent  streptococci  in  rapid  multi- 


58  ETIOLOGY  OF  ERYSIPELAS. 

plication  are  only  destroyed  by  very  strong  antiseptics  of 
escharotic  action  makes  it  impossible  to  prevent  the  infection  in 
every  case.  Think  of  a  virulent  streptococcus  infection  of  the 
mastoid.  It  is-  a  physical  impossibility  to  prevent  a  possible 
infection  of  the  freshly-wounded  soft  parts  while  the  diseased 
bone  is  being  slowl}^  and  carefully  chiseled  and  curetted  away. 
Or,  again,  think  of  the  infected  frontal  sinus,  tense  with  pus, 
with  its  exit  closed  by  inflammatory  swelling  and  colonies  of 
streptococci  penetrating  the  mucous  membrane,  invading  the 
periosteum  and  eroding  the  upper  layers  of  the  bone.  In 
some  cases  thorough  exenteration  of  the  sinus  and  the  ethmoid 
cells  cannot  possibly  reach  and  destroy  every  fold  and  crevice 
of  the  latter  which  harbor  the  multiplying  streptococci,  and  a 
thorough  operation  necessarily  involves  most  extensive  wounds 
of  the  skin  and  subcutaneous  tissue,  the  mucous  membrane  and 
submucous  tissues,  the  periosteum  and  the  bone.  And  yet 
the  more  violent  the  imflammatory  process,  the  greater  proba- 
bility, theoretically,  that  we  are  in  the  presence  of  a  virulent 
infection,  the  more  imperative  it  is  that  we  should  immediately 
evacuate  the  pus  cavity  through  a  wound  of  our  own  making 
that  drainage  may  be  rapid,  direct  and  free,  and  the  life  of  our 
patient  be  not  imperilled  by  a  streptococcic  invasion  of  the 
cranial  cavity,  the  meninges  and  the  brain. 

I  submit  that  we  have  reached  that  point  in  our  knowledge 
of  this  subject  where  we  can  say  with  positiveness  that  ery- 
sipelas is  a  streptococcus  infection  which  is  almost  invariably 
an  autoinfection  from  the  upper  air  tract  of  the  patient,  and 
that  in  those  rare  cases  where  it  is  not  an  autoinfection  the 
infection  is  derived  from  the  air  passages  of  some  one  in  con- 
tact with  the  patient  in  some  capacity.  Modern  knowledge  of 
contagion  and  modern  methods  of  cleanliness  have  practically 
entirely  done  away  with  the  old  epidemics  of  erysipelas  that 
used  to  invade  hospitals  or  communities  some  thirty  or  forty 
years  ago. 

In  the  prosecution  of  this  study  I  have  been  struck  by  the 
comparative  frequency  of  a  serious  involvement  of  the  eyes 
and  ears  in  the  course  of  a  facial  erysipelas.  That  corneal 
ulcers  or  a  keratomalacia  should  appear  as  a  result  of  the 
violent  inflammation  of  the  lids  and  the  tremendous  pressure 
of  the  palpebral  edema  is  not  to  be  wondered  at,  but  the  fact 
of  the  matter  is,  that  a  variety  of  conditions  supervene  from 
apparently  an  identical  cause,  streptococcus  infection,  and  the 


ETIOLOGY  OF  ERYSIPELAS.  59 

resultant  pathological  state  must  be  determined  by  the  local 
conditions  existing  in  each  patient.  Apparently,  we  never  or 
rarely  see  some  of  these  conditions  in  America.  For  instance, 
the  French  frequently,  and  the  Germans  occasionally,  speak 
of  a  chronic  thickening  of  the  lids  which  occurs  as  the  result 
of  recurrent  facial  erysipelas,  and  resembles  the  condition  of 
the  skin  in  elephantiasis.  Lavrand  was,  I  believe,  the  first  to 
describe  this  condition  which  he  observed  in  a  boy  of  15. 
There  was  no  condition  of  the  eye  itself  which  would  afford  an 
explanation  of  this  strange  phenomenon  and  Lavrand  there- 
fore connected  it  etiologically  with  a  facial  erysipelas  which 
had  recurred  again  and  again  and  had  always  originated  in 
the  nasopharynx.  The  mucosa  of  the  nose  was  swollen  and 
Luschka's  gland  was  enlarged.  The  treatment  of  this  condi- 
tion healed  the  affection  of  the  lids.  The  correctness  of  this 
observation  was  subsequently  confirmed  by  others.  Parinaud, 
Uhthoff  and  Winckler  have  given  us  excellent  descriptions 
of  the  various  forms  of  streptococcus  conjunctivitis  and  have 
connected  these  directly  with  disease  of  the  lachrymal  drain- 
age apparatus,  which  as  we  know  is  itself  a  result  of  an  in- 
flammation of  the  nasal  mucous  membrane.  Indeed,  Winck- 
ler says,  "The  streptococci,  as  well  as  the  staphylococci,  which 
can  produce  acute  inflammation  of  the  mucosa  of  the  upper 
respiratory  tract,  must  be  considered  as  etiologic  factors  in 
conjunctivitis." 

Most  authors  who  describe  cases  of  atrophy  of  the  optic 
nerve  consecutive  to  attacks  of  facial  erysipelas  appear  to 
consider  that  this  is  a  compression  atrophy  due  to  orbital 
edema  or  abscess.  This  view,  as  you  will  observe  from  the 
cases  cited,  cannot  always  be  borne  out  by  the  s3^mptoms 
present  or  the  results  of  physical  examination.  Hajek  (86), 
the  rhinologist,  has  pointed  out  that  "The  dissemination  of  the 
streptococcus  in  an  erysipelatous  eye  is  sufficient  cause  by 
itself.  Their  power  to  do  harm  is  proportionate  to  the  toxins 
they  produce.  Their  growth  in  the  lympathics  extends  in  all 
directions  so  that  they  travel  in  dense  masses  in  the  direction 
of  the  interstitial  spaces  and  they  also  penetrate  the  tissues 
themselves  in  every  direction.  If  the  erysipelas  involves  the 
orbit  they  wander  to  Tenon's  capsule,  from  here  to  Tenon's 
space  .and  the  optic  disc,  eventually  then  to  the  prolongations 
of  the  pia  about  the  nerve  and  into  .the  connective  tissue  which 
ensheathes  the  central  vessels  of  the  optic  nerve.     Even  the 


60  ETIOLOGY  OF  ERYSIPELAS. 

walls  of  the  vessels  are  penetrated  by  the   cocci  and  thus 
changes  are  produced  in  the  vessels  themselves." 

In  conclusion,  I  would  submit  for  your  consideration  the 
following  cases  of  ocular  and  aural  complications  due  to  and 
occurring  in  the  course  of  erysipelas  of  the  face,  observing 
merely  that  they  illustrate  exhaustively  the  conditions  that  have 
been  discussed  in  the  paper. 

Woman,  aged  50.  Five  attacks  empyema  right  frontal  sinus, 
five  months.  Upper  lids  swollen  and  edematous,  bony  walls 
tender.  Eye  normal.  Anterior  extremity  right  middle  turbi- 
nal  bathed  in  pus.  Middle  turbinectomy.  Two  days  later 
frontal  sinus  operation.  On  the  following  day  pain.  T.  100 
F.  On  second  day  dressings  were  changed ;  some  edema  of 
upper  lid  and  slight  exophthalmos;  wound  clean;  on  raising 
lid  patient  exclaimed  she  could  not  see.  Pupil  fixed  and  semi- 
dilated.  Ophthalmoscopically  retina  hazy  and  edematous ; 
arteries  small,  inferior  temporal  artery  obliterated ;  no  swelling 
of  disc.  Three  small  hemorrhages  about  macula.  Later  atrophy 
and  total  blindness.  The  frontal  sinus  wound  healed  promptly. 
In  the  discussion  which  followed,  Dr.  Meierhof  stated  that  he 
thought  the  condition  was  produced  by  a  secondary  orbital 
cellulitis. — Arnold  H.  Knapp,  Archives  of  Ophthalmology^  Vol. 
XXX,  p.  308.  (Compare  this  case  with  that  of  E.  E.  Foster, 
New  Bedford,  Mass.,  and  case  of  J.  H.  Farlow,  Boston,  Mass.) 

Girl  of  18.  Entered  hospital  for  her  second  attack  of  ery- 
sipelas, the  first  having  begun  at  the  ala  of  the  nose.  Each 
attack  occurred  at  a  menstrual  period.  Severe  attack.  Several 
days  after  convalescence  began,  vision  failed  in  one  day  and 
she  was  not  able  to  count  fingers.  Ophthalmoscopic  examma- 
tion  revealed  atrophy  of  the  optic  nerves.  Nothing  abnormal 
with  the  yellow  spot,  the  retina  or  the  choroid. — These  de 
Bordeaux,  1887,  Colle. 

Erysipelas  following  a  wound  of  the  lid.  The  right  eye 
was  closed  for  one  month — when  opened  was  completely  blind. 
Paralysis  lev.  palp.  sup.  All  the  movements  of  the  eye  limited. 
Opacities  of  the  lens.  Disc  pale.  Vessels  reduced,  many  com- 
pletely empty.  Pigmented  spots  in  region  of  macula. — British 
Medical  Journal,  1878. 

Erysipelas,  orbital  abscess.  Protrusion  and  immobility  of  the 
globe,  chemosis.  Tumefaction  of  the  lids  which  were  not  able 
to  cover  the  globe.  Ophthalmoscopically  the  fundus  appeared 
whitish,  studded  with  numerous  hemorrhages,  arteries  invisible, 


ETIOLOGY  OF  ERYSIPELAS.  61 

numerous  veins  dilated. — Knapp,  Revue  d'ophthalmologie  de 
Dor  et  Meyer,  1885. 

Woman,  aged  68.  Three  months  previously  facial  erysipelas 
followed  by  an  orbital  abscess.  Rapid  diminution  of  vision  of 
right  eye.  Ophthalmoscopically,  notwithstanding  an  immature 
cataract,  one  could  determine  an  optic  atrophy  V=o. — Ramirez 
N.  Montpellier  Med.,  1897. 

Woman.  Severe  attack  of  facial  erysipelas.  Abscesses,  etc., 
of  the  lids.  Exophthalmos.  Mobility  intact.  Cornea  clear. 
Anterior  chamber  normal.  Posterior  synechia.  Lens  and 
media  clear.  Ophthalmoscopically,  left  eye  disc  greyish  white, 
slightly  excavated,  vessels  reduced.  Vision  abolished. — ^Ca- 
bannes.  These  de  Bordeaux  par  Fauveau,  1903-1904,  No.  94. 

In  a  thesis  at  Basle,  1882,  Anton  Schwendt  gives  the  fol- 
lowing statistics :  He  studied  44  cases  of  phlegmon  of  the  orbit, 
followed  by  diminution  or  loss  of  vision.  Sixteen  cases  were 
due  to  erysipelas  of  the  face,  4  of  which  had  a  fatal  termination 
through  thrombosis  of  the  sinus  or  meningo-encephalitis.  The 
author  added  to  this  group  4  cases  not  figuring  in  the  statistics, 
where  an  erysipelas  was  followed  by  atrophy  of  the  optic 
nerve  and  in  which  the  inflammation  of  the  cellular  tissue  of 
the  orbit  was  not  demonstrated,  although  probable.  As  a 
cause  of  abscess  erysipelas  entered  into  more  than  1/3  of  the 
cases.  These  cases  consecutive  to  erysipelas  are  very  menacing 
to  the  vision.  In  Schwendt's  collection  of  18  attacked  not  one 
recovered.  These  phlegmons  reveal  a  high  mortality — 30.7 
per  cent— These  de  Bordeaux,  Colle,  1886-1887,  No.  106. 

Chambermaid,  aged  30.  Attack  of  erysipelas  of  moderate 
severity,  terminating  on  the  eighth  day.  Edema  of  the  lid, 
hyperemia  of  the  conjunctivae — double  iritis  with  posterior 
synechiae.  Recovery.  Vidal,  Gazette  Med.  de  Paris,  No.  44, 
1862. 

Floating  opacities  formed  in  the  vitreous  humor,  constitut- 
ing a  network  interrupted  here  and  there  by  membranes  in 
shreds  during  the  course  of  a  facial  erysipelas.— Mathias,  Re- 
cueil  de  medicine  militaire,  1869. 

Among  eight  observations  gathered  by  the  author  there  were 
five  monocular  optic  nerve  atrophies  and  three  that  were 
binocular.  In  the  five  monocular  cases  the  erysipelas  had  in 
two  cases  been  consecutive  to  a  wound  of  the  same  side  which 
had  not  directly  injured  the  eye.  In  four  cases  the  erysipelas 
had  been  more  pronounced  on  or  else  limited  to  the  side  on 


62  ETIOLOGY  OF  ERYSIPELAS. 

which  the  optic  atrophy  had  occurred.  In  three  cases  paresis 
of  the  lev.  palp,  sup.,  restriction  of  movement  of  globes,  slight 
exophthalmos,  but  no  decided  evidence  of  orbital  abscess.  In 
all  cases  loss  of  vision  appeared  during  the  course  of  the  ery- 
sipelas. The  sound  eye  was  not  attacked  following  the  atrophy 
of  the  nerve. — Parinaud,  Journal  de  medicine  et  de  chirurgie 
pratique,  Oct.,  1879. 

In  discussing  cases  of  this  character  Panas  said,  "Numerous 
anastamoses  of  the  ophthalmic  vein  are  known.  Recently 
Gurtwisch  has  again  demonstrated  by  beautiful  injections  that 
numerous  vessels  unite  the  ophthalmic  to  the  veins  of  the 
pterygo-maxillary  fossa  and  in  particular  the  spheno-palatine." 
^Semaine  medicale,  1885. 

Lapersonne  said  also  that  phlebitis  of  the  ophthalmic  vein 
and  of  the  cavernous  sinus  was  known  to  have  been  caused 
by  lesions  of  the  mouth,  pharynx,  lips  and  nasal  fossae,  such 
as  septic  wounds,  furuncles,  anthrax  and  especially  erysipelas. — 
Semaine  medicale,  1885. 

Death  on  the  ninteenth  day  of  a  facial  erysipelas  after  de- 
lirium, grinding  of  the  teeth,' muscular  contractions,  pupillary 
irregularity.  On  the  thirteenth  day  coma,  dilated  pupils,  para- 
lysis. On  autopsy,  thrombosis  of  the  ophthalmic  vein  and  the 
tranverse  sinus  with  cloudy  effusion  into  the  arachnoid.  Weber 
quoted  by  Colle.— These  de  Bordeaux,  1886-1887,  No.  106. 

Ripault  refers  to  a  case  exhibiting  crops  of  chalazia  after 
facial  erysipelas  and  makes  the  following  citations  without 
giving  the  name  or  date  of  publications :  Annular  bands  or 
paracentral  plaques  of  the  cornea,  losses  of  substance  border- 
ing upon  perforation  of  the  lens  (Gallsowski).  Acute  iritis 
monocular  or  binocular  (Hanson,  Vidal).  Tardy  iritis  oc- 
curring in  convalescence,  analogous  to  that  of  typhoid  or  va- 
riola (Dor).  Neuroretinitis  with  retinal  hemorrhages  (Sat- 
tler).  Neuroretinitis  due  to  numerous  microbial  embolisms 
(Nernheiser).  Thrombosis  of  the  central  vein  (Knapp).  De- 
tachment of  the  retina  (Heineche).  Des  complications 
oculaires  de  I'erysipele  de  la  face  (H.  Ripault).  Gazette  Medi- ■ 
cale  de  Paris,  April  20th,  1895. 

Case  of  facial  erysipelas.  "One  week  after  the  beginning 
of  an  attack,  without  previous  pain  or  special  local  swelling 
and  without  any  symptoms  in  the  throat  or  nose,  pus  began 
to  flow  from  the  right  ear.  At  this  time  the  walls  of  the 
external   auditory  canal   were  normal   and  the  pus   obviously 


ETIOLOGY   OF  ERYSIPELAS.  63 

came  from  the  middle  ear  through  an  opening  in  the  drum 
head." — ^J.  A.  Lippincott,  Medical  Nezvs,  Philadelphia,  1890, 
LVII,  p.  309. 

Woman,  aged  70.  Erysipelas  of  the  face  having  begun  at 
the  nasal  orifice  on  the  right  half  of  nose  and  cheek.  Throat 
red  and  tongue  dry.  Followed  by  optic  neuritis  and  atrophy 
after  edema  of  the  lids,  exophthalmos,  ophthalmoplegia  externa, 
chemosis,  pupils  dilated  one-half  and  clear  cornea. — F.  Ter- 
rien,  Xeurite  et  atrophic  optique  au  cours  de  I'Erysipele. 
Progres  Med.  Paris,  1904,  XX,  p.  165. 

Man,  aged  53.  Facial  erysipelas  that  began  on  mucous 
membrane  of  the  lower  lip.  Intense  earache.  Pharyngitis. 
Rhinitis  with  tumefaction.  Rupture  of  M.  T.  Mastoid  red  and 
tender.  Paracentesis  ]\I.  T.  Recovery. — H.  V.  Wiirdemann, 
Medical  Nezvs,  Nov.  21st,  1891. 

Unilateral  orbital  abscess,  optic  neuritis  and  blindness  fol- 
lowing facial  erysipelas  in  which  there  was  a  continual  puru- 
lent discharge  from  the  corresponding  nostril. — Carl,  quoted 
by  Fish,  American  Journal  of  Surgery,  Sept.,  1906. 

Case  of  erysipelas,  redness  and  swelling  of  the  inner  corner 
of  the  eye,  much  periorbital  pain,  considerable  ptosis,  limita- 
tion of  movement,  orbital  fistula  in  upper  and  lower  lid,  no 
perception  of  light.  "Several  months  before  the  attack  he 
had  for  a  considerable  time  a  yellow  discharge  from  the 
nostrils,  sometimes  offensive.  This  had  quite  ceased  before 
the  erysipelas  and  there  seems,  therefore,  very  little  reason 
for  supposing  that  the  orbital  inflammation  was  propagated 
from  the  nose."  (  !) — Nettleship  quoted  by  Fish,  American 
Journal  of  Surgery,  Sept.,  1906. 

Man,  aged  53.  Incision  of  abscess  of  brow  followed  by 
erysipelas.  Edema  of  the  lids.  Chemosis.  On  ninth  da}^  the 
cornea  became  lustreless,  pupil  hazy,  anterior  chamber  reduced, 
tension  plus.  Delirium,  coma  and  death  on  tenth  day. — Warlo- 
mont,  Ann.  d'Oculistique,  Paris,  T.  LXVI,  X'ov.-Dec,  1871. 

Woman,  aged  40.  Abscess  inner  canthus  right  eye.  Stra- 
bismus internus.  Rapidly  spreading  excoriation  lower  one- 
third  cornea,  hypopyon  and  iritis.  Anesthesia  cheek  and  con- 
junctiva. Prolapsus  and  phthisis  bulbi  threatened.  Patient 
recovered  with  lower  two-thirds  of  cornea  opaque. — X^eve, 
Brit.  Med.  Journal,  1886,  Vol.  1. 

A  serpiginous  ulcer  occurred  on  the  lower  third  of  the 
cornea.     Microscopically  it  resembled  a   diphtheritic  inocula- 


64  ETIOLOGY  OF  ERYSIPEIvAS. 

tion. — Horner,  Klin.  Monatsbl.  f.  Augenheilkunde,  1875,  s. 
442. 

Woman,  aged  32.  Erysipelas  after  the  extraction  of  a  tooth 
which  had  caused  a  swelHng  of  the  jaw.  Skin  of  left  upper 
lid  deep  violet,  smooth,  glistening.  Enormous  chemosis,  pal- 
pebral and  ocular  conjunctiva.  Closure  of  palpebral  fissures 
impossible.  Exophthalmos.  Dislocation  of  globe  outward. 
Orbital  abscess,  haziness  of  cornea,  iritis,  pupillary  exudate, 
amaurosis,  phthisis  bulbi. — Fetzer  in  Arlt's  Bericht  uber  die 
Augenklinik  der  Wiener  Universitdt,  1863  bis  1865,  Wien 
1867,  s.  116. 

Woman,  aged  30.  Erysipelas  four  years  previously.  An- 
chyloblepharon.  Staphyloma  corneae  requiring  enucleation. 
Examination  showed  previous  ulceration  and  adhesion  to  tarsal 
connective  tissue. — Kimeni,  Bullet.  d'Oculist,  T.  IX,  p.  17. 

Circumocular  erysipelas  after  blepharoplasty  on  left  eye. 
Corneal  ulcer,  perforation,  general  haziness  and  softening. 
Phthisis  bulbi  and  cicatricial  shrinking  of  the  lid. — Warner, 
Klin.  Monatsbl.  f.  Augenheilk.,  1872,  s.  387. 

Seventy-seven  cases  ocular  involvement  in  the  course  of  ery- 
sipelas ;  16  cases — involvement  of  lids  and  orbit  without  affec- 
tion optic  nerve ;  37  cases — involvement  of  lids  and  orbit  with 
affection  optic  nerve ;  13  cases — involveijient  of  optic  nerve 
without  orbital  disease;  7  cases — involvement  of  uveal  tract. — 
Lewin  &  Guillery,  Die  Wirkungen  v.  Artzneimitteln  u.  Giften 
auf  das  Auge,  Vol.  2,  p.  31.    Berlin,  1905. 

Erysipelas  with  gangrene  of  the  four  lids. — Castresani 
Spanish- Am  eric.  Ophthal.  Gessllsch.,  ApL,  1904. 

Secondary  involvement  of  the  lachrymal  organs.  Cane,  Ga- 
zette de'Ophthalm.,  1882.  No.  5. 

Thirty-five  cases  of  orbital  cellulitis  with  a  mortality  of  29 
per  cent.  Of  the  cases  which  survived  there  were  blind ; 
bilaterally,  60  per  cent,  incomplete  recovery  of  vision,  12  per 
cent,  complete  recovery  of  vision,  12  per  cent.  Knapp,  Archiv. 
f.  Augenheilk.,  Bd.  XIV,  p.  257. 

(a)  Exophthalmos,  necrosis  of  the  lid,  ulceration  of  the 
cornea,  vision  unaffected,  (b).  Edema  and  abscess  of  the 
lids.  fc).  Chronic  rhinitis  with  erysipelas.  Acute  abscess 
of  the  upper  lids.  Necrosis  of  the  skin  of  lids.  Sloughing 
with  exposure  of  orbicularis  muscle.  Streptococci  in  pus. — 
Mitvalsky,  Klin.  Monatsbl.  f.  Augenheilk.,  1893,  s.  18.  Aschen- 
born,  Archiv.  f.  Klin.  Chirurgie,  XXV,  s.  154. 


ETIOI.OGY  OF  ERYSIPEI.AS.  QQ 

Girl,  aged  25  years.  Edema  of  lids.  Chemosis,  subcon- 
junctival hemorrhage.  Ophthalmoplegia  externa.  Dislocation 
lachrymal  gland.  Exophthalmos.— Imre,  Klin.  Monatsbl.  Au- 
genheilk.,  1876,  s.  187. 

Man,  26  years.  Edema  of  the  lids,  hyperemia  of  the  con- 
junctiva, slight  exophthalmos,  chemosis  inner  canthus,  oph- 
thalmoplegia externa.  Orbital  abscess.  Complete  recovery.— 
Williams,  Boston  Med.  and  Surg.  Jour.,  Vol.  CVZII,  p.  51. 

Boy  of  6  years.  Edema  of  the  lids.  Exophthalmos  right 
eye.  Ophthalmoplegia  externa.  Chemosis  lower  half  ocular 
conjunctiva.  Orbital  abscess.  Complete  recovery  after  two 
and  one-half  months. — Williams,  loc.  cit. 

Bilateral  inflammation  of  the  retrobulbar  connective  tissue. 
Brain  was  not  involved  and  there  was  complete  restitution  of 
vision. — de  Smet,  La  Presse  Medicale,  1878,  p.  137. 

Girl  of  15  years.  Edema  of  lids,  chemosis,  exophthalmos. 
Congestion  and  tortuosity  of  veins  of  right  fundus.  Epidural 
abscess  in  temporal  and  middle  cerebral  fossa,  necessitating 
chiseling  away  of  zygomatic  process  of  frontal  and  the  frontal 
process  of  zygomaticus  down  to  the  ala  magna  of  the  sphenoid  • 
also  removal  of  temporal  wall  of  orbit.  Recovery  without  in- 
jury to  eyeball  or  vision.— Nieman,  Inaug.  Dissertation  Griefs- 
wald,  1901,  s.  7. 

Small  abscess  right  upper  lid.  Erysipelas.  Exophthalmos 
gradually  disappeared  in  the  course  of  a  year.— Lippincott, 
Trans.  Am.  Ophthal.  Sac,  Boston,  1885,  p.  702. 

Cryptic  erysipelas  in  a  girl  of  9  months  who  had  previously 
been  perfectly  healthy.  Convulsions,  orbital  abscess.  Libera- 
tion of  pus  containing  streptococci  and  staphvlococci.  Re- 
covery.—Bull  e  tin  et  Mem.  de  la  Societe  francaise  d'ophthal- 
mologie,  1898,  p.  57. 

Man,  aged  39.  Erysipelas  after  fever  and  pain  in  bottom 
of  right  eye.  Edema  of  lids.  Tenth  dav,  gangrene  of  lids. 
Exophthalmos  right  eye.  Ophthalmoplegia  exte'^rna.  Cornea 
hazy,  dry,  non-sensitive.  Pupil  irresponsive.  Yellowish  cloudy 
mass  m  fundus.  T.  +.  Rupture  of  globe  emitting  offensive  pus 
Removal  of  lids.  Enucleation  of  globe.  Necrosis  and  slough- 
mg  of  orbital  tissue.— Biermann,  Klin.  Monatsbl.  f  Auzen- 
heilk.,  1869,  s.  91.  . 

Primipara,  33  years.  Nasopharyngeal  catarrh.  Erysipelas 
two  days  after  delivery.  Edema  of  lids.  Gangrene  'skin  of 
right  hd  from  the  lashes  to  the  brows.     Streptococci  in  the 


66  ETIOLOGY  OP^  ERYSIPELAS. 

necrotic  masses.  Bulbar  conjunctiva  ulcerated.  Small  ab- 
scesses in  lower  part  of  cornea.  Exophthalmos,  amaurosis, 
orbital  abscess.  Iris  discolored,  pupil  small  and  adherent  to 
lens.  Hypopyon,  corneal  perforation,  prolapse  of  iris.  Ex- 
enteration of  globe.  .Ectropion  both  lids. — ^Joss.  Corre- 
spondenzbl.  f.  Schweitzer  Aerzte,  Bd.  XXXI,  1901,  s.  617. 

Erysipelas  after  shelling  out  an  orbital  cyst.  Panophthal- 
mitis.— Kraotschenko,  Ahhandl.  der  Gesellsch,  russ.  Aerzte  su 
Petersburg.    Jahrg.  LIV,  s.  125. 

A  man  of  38  had  had  a  phlegmonous  facial  erysipelas  while 
a  child.  As  a  result  of  this  the  entire  face,  including  the  nose, 
ears  and  eyelids,  had  been  converted  into  a  smooth  cicatrix. 
The  nose  and  the  mouth  were  each  designated  by  an  opening. 
In  the  mouth  could  be  seen  the  atrophic  tongue  grown  fast  to 
the  alveolus  and  one  remaining  tooth.  The  eyelids  could  be 
felt  through  the  skin. — Santos  Fernandes.  OphthalmoL 
Klinik,  1900,  No.  14. 

Woman,  aged  60.  Involvement  of  right  lachrymal  sac. 
Edema  of  lids  with  formation  of  blebs.  Coma,  delirium  and 
death  on  fifth  day.  Autopsy  revealed  abscesses  about  nasal 
duct  in  the  right  lid  and  in  the  orbit. — Piorry,  Cliniqiie  Medi- 
cal, 1833,  p.  381. 

Man,  aged  42.  Pustules  of  lids.  Orbital  abscess.  Death 
on  the  thirteenth  day.  Autopsy.  Bilateral  orbital  abscess. 
Both  globes  atrophic.  Pus  in  Tenon's  capsule.  Vein  of  fissure- 
of  Sylvius  tense  with  yellow  contents.  Yellow  fluid  in  sub- 
arachnoid spaces.  Cerebral  necrosis.  Nucleus  of  right  lens 
contained  an  area  filled  with  micrococci. — Schiile,  Archiv.  f. 
pathol.  Anatomie,  Bd.  LXVII,  s.  125. 

Boy  of  5  years.  Contusion  of  left  eyelid.  Erysipelas.  Third 
day  exophthalmos  both  globes.  Fifth  day  orbital  abscess 
(left)  opened  spontaneously.  Ulceration  right  cornea,  per- 
foration. Death  eleventh  day.  Autopsy.  Pus  in  cavernous 
sinus  and  middle  cerebral  fossa.  Abscess  right  orbit  and  dif- 
fuse purulent  infiltration  of  orbital  fat.  Small  abscess  in  left 
orbit. 

Man  of  43.  Exophthalmos  left  globe.  Ophthalmoplegia 
externa.  Chemosis.  Later,  chemosis  right  eye.  Left  frontal 
vein  could  be  felt  as  hardened  cord.  Delirium,  stupor,  facial 
paralysis,  death  in  six  days.  Autopsy.  Dura  at  base  of  middle 
cerebral  fossa  covered  by  punctate  extravasations  and  an 
exudate.  The  optic  nerves  in  their  foramina  were  surrounded 
by  pus.    Pia  at  the  base  infiltrated  with  pus.    Islands  of  pus  in 


ETIOLOGY  OF  ERYSIPELAS.  67 

the  orbit,  in  the  ocular  muscles  and  along  the  veins. — Bayle, 
Prager  med.  Wochenschr.,  1881,  s.  221. 

Girl  of  15  years.  Abscess  of  lip.  Incision.  Erysipelas. 
Exophthalmos.  Right  pupil  fixed.  Death  in  six  days.  Au- 
topsy. Purulent  phlebitis  left  anterior  facial  vein  which  ex- 
tended into  the  left  superior  sinus  petrosus.  Orbital  tissues 
were  edematous. — Cohn,  Klin,  der  embol.  Gefasskrank., 
1860,  s.  196. 

Out  of  221  cases  of  optic  atrophy,  14  were  due  to  erysipelas. 
— Uhthoff,  Klin.  Monatsbl.  f.  Augenheilk.,  1900,  s.  533. 

Of  51  cases  of  erysipelas  in  which  the  vision  became  affected 
there  were  changes  in  the  fundus  of  the  eye  in  37.  The  fundal 
changes  were  unilateral  in  25  cases  and  bilateral  in  12  cases. 
Convalescence  with  complete  or  partial  restoration  of  sight 
occurred  8  times  or  in  16  per  cent  of  the  cases. — Lewin  & 
Guillery,  Dei  Wirkungen  von  Arztzeimittel  und  Giften  auf  das 
Auge,  Vol.  2,  p.  31.    Berlin,  1905. 

Girl,  aged  12  years.  Left  globe,  ophthalmoplegia  externa, 
exophthalmos,  connective  tissue  red  and  edematous.  High 
grade  of  amblyopia.  Meningeal  symptoms  and  death  on  the 
eighth  day. — du  Gourlay,  Annales  d'Oculistique,  T.  CXXX,  p. 
199. 

Man,  aged  28.  Infiltration  of  the  lids.  Exophthalmos  left 
eye.  Orbital  abscess,  ophthalmoplegia  externa,  amaurosis,  per- 
forating ulcer  of  cornea,  phthisis  bulbi.  After  several  weeks, 
death  due  to  bronchitis  and  debility.- — Noyes,  Richmond  and 
Louisville    Medical  Jour.,  July,  1875,  p.  856. 

Girl,  aged  20.  Bilateral  abscess  of  orbit.  No  suppuration 
in  either  eye,  but  there  was  a  total  and  complete  amblyopia 
with  dilated  pupils. — Demarquay,  Traite  des  tumeurs  de 
I'orbite,  1860,  p.  134. 

Man,  aged  60.  Abscesses  of  the  left  lids.  Improvement  after 
incision.  About  two  weeks  later  increasing  chemosis,  exo- 
phthalmos, diminished  rotation  and  amaurosis.  Greyish  yellow 
discoloration  of  the  fundus  and  slight  contraction  of  retinal 
vessels.  Orbital  abscess.  Amblyopia  permanent.  Optic 
atrophy. — Williams,  Boston  Med.  and  Surg.  Jour.,  Vol.  CVIII, 
p.  51. 

Man,  aged  64.  Abscess  right  lids.  Chemosis.  When  eye 
could  be  opened  was  found  amaurotic.  Exophthalmos,  but  no 
discoverable  orbital  abscess.  Atrophic  changes  in  disc.  Ves- 
sels contracted.     Amaurosis  permanent. — Williams,  loc.  cit. 


68  ETIOLOGY  OF  ERYSIPELAS. 

Man,  aged  41.  Erysipelas  after  a  fall.  Right  eye  closed  for 
four  weeks.  When  finally  opened  totally  blind.  Cornea  clear, 
pupil  dilated  and  immobile,  media  hazy,  disc  pale  bluish, 
atrophic  appearance.  Arteries  contracted,  some  empty  and 
some  contained  blood  only  in  spots.  Accumulations  of  pig- 
ment in  region  of  macula. — Benson,  Brit.  Med.  Jour.,  1878, 
Vol.  1,  p.  371. 

Man,  aged  64.  Gangrene  of  lids.'  Corneal  epithelium  ne- 
crotic. Exophthalmos,  ophthalmoplegia  externa.  Retinal  ves- 
sels in  both  eyes  empty,  with  one  exception.  Disc  of  a  grayish 
white  discoloration.    Coggin,  Am.  Oph.  Soc,  1879, 11,  p.  570. 

Gangrene  of  both  lids  of  each  eye.  Orbital  involvement. 
Optic  atrophy. — Globe  not  affected. — Arlt,  quoted  by  Eewin 
and  Guillery,  loc.  cit. 

Serious  involvement  of  the  meninges. — Biermann,  Klin. 
Monatsbl.  f.  Augenheilk.,  1869,  p.  91. 

Man  of  48.  Lost  perception  of  light  four  weeks  after 
onset  of  erysipelas.  Disc  pale,  arteries  reduced.  Pupils  react 
to  accommodation  and  convergance,  but  not  to  light.  Ptosis 
and  ophthalmoplegia  externa.  Orbicularis  palpebrarum 
paralyzed.  Orbital  abscess. — Nettleship,  Trans.  Ophth.  Soc. 
United  Kingdom,  182,  Vol.  II. 

Man  of  23.  Optic  atrophy  produced  by  compression  by  the 
edematous  orbital  tssues. — Despaquet,  Recueil  d' Ophthalmol., 
1880,  p.  176. 

Man  of  51.  On  the  third  day  of  erysipelas,  exophthalmos, 
amaurosis,  ophthalmoplegia  externa.  Edema  of  the  lids,  ulcer 
of  the  cornea;  later,  macula.  Optic  disc  white  and  completely 
atrophic. — Schiess,  bei  Schwendt,  Ueber  Orbitalphlegmone, 
Basle,  1882. 

Man  of  63.  Edema  of  the  left  lids,  closing  palpebral  fissure. 
Diminished  rotation  and  tenderness  of  globe.  When  lids 
could  be  opened,  complete  amaurosis.  Sharply  defined  white 
disc.  Paralysis  levator  superior.  Palp. — Pagenstecher,  Klin. 
Monatsbl.  f.  Augenheilk,  1870,  s.  270. 

Man  of  49.  Erysipelas.  Eyes  closed  two  weeks.  Two 
months  later  V=15/100  R.  and  L-  Discs  reddish  white,  sharply 
defined.  Vessels,  especially  arteries,  diminished  in  lumen.  F.  V. 
contracted  and  "a  sharply  defined  dimness  of  vision  about  the 
point  of  fixation." — Pagenstecher,  loc.  cit. 

A  soldier  had  had  three  attacks  of  erysipelas.  Six  months 
after  the  last  attack  the  upper  lids  were  swollen  and  drooping. 
Slight  external  strabismus  and  dilatation  of  the  pupils.  V=:l/5. 


ETIOI^OGY  OF  ERYSIPELAS.  69 

Central  scotoma.  The  centre  of  the  disc  showed  beginning, 
atrophy,  the  periphery  was  edematous.  There  were  several 
atrophic  patches  in  the  choroid.  An  inflammation  of  the 
sheaths  of  the  optic  nerves  was  accepted  as  a  cause. — Dufaut, 
L' Union  Medicale,  1886,  No.  171,  p.  1002. 

Erysipelas  with  exophthalmos  and  chemosis  and  great  edema 
of  the  lids  for  four  weeks.  After  opening  the  right  eye  it  was 
totally  blind.  Changes  in  me  blood  vessels  and  haziness  of 
the  retina. — Schmaller,  Archiv.  f.  Ophthalmol.,  Vol.  VII, 
Part  1. 

An  elderly  man,  with  great  edema  of  the  lids  for  several 
days.  When  it  was  possible  to  open  them  the  right  eye  was 
blind.  Disc  pale,  and  white  on  macular  side ;  arteries  reduced. 
—Hutchinson,  Ophthal.  Hosp.  Rep.,  V.  7,  1871. 

Pregnant  woman  of  43.  Six  weeks  after  onset  of  erysipelas 
right  circumocular  tissues  still  infiltrated,  movements  normal, 
pupils  dilated  and  fixed,  cornea  clear,  disc  white.  Left  globe 
ophthalmoplegia  externa,  abscess  of  cornea,  prolapse  of  iris; 
later  phthisis  bulbi.     Death. — .Schiess,  bei  Schmidt,  1.  c.  331. 

Woman  of  27.  Edema  of  lids,  exophthalmos,  chemosis,  or- 
bital abscess.  Pupils  small.  Both  eyes  amaurotic,  discs  pale, 
vessels  contracted.  On  the  eighth  day,  fingers  could  be  count- 
ed. Fourteenth  day  corneal  ulcer  on  right  eye  followed  by 
perforation.    L.  V.=6/9 — Bayer,  1.  c,  p.  222. 

Girl  of  10.  Edema  of  the  lids  on  right,  exophthalmos,  oph- 
thalmoplegia externa,  chemosis.  V=fingers,  15  feet.  Corneal 
ulcer.  Orbital  abscess.  Amaurosis.  Perforation  of  cornea, 
with  escape  of  lens  and  vitreous.  Phthisis  bulbi. — Leber,  Ar- 
chiv. f.  Ophthal,  Bd.  XXVI,  Part  3. 

Both  eyes  affected.  One  with  optic  atrophy  and  a  white  disc, 
which  showed  an  edematous  margin,  and  the  other  a  neuro- 
retinitis,  which  shortly  thereafter  underwent  atrophy. — Lubin- 
sky,  Klin.  MonatsU.  f.  Augenheilk,  1878,  s.  168.  Nettleship,  1.  c. 

Papillitis  with  pronounced  exophthalmos  downward.  Re- 
covery.— Karafiath.     Szemeszet,  1884,  I,  p.  64. 

Chorio-retinitis  and  maceration  of  the  pigment  in  the  region 
of  the  macula  lutea.  Atrophy  of  the  pigment  epithelium  about 
the  vessels.  A  wide  band-like  zone  of  atrophic  pigmented  epi- 
thelium between  the  macula  and  the  disc  — Hoesch,  Ueber 
Erkrankungen,  etc.,  Berlin,  1881.  Herodes,.  Inaug.  Disser., 
Wiirzburg,  1888.  Carl,  Klin.  Monatsbl.  f.  Augenheilk.,  1884, 
S.  113. 


70  ETIOLOGY   OF   ERYSIPELAS. 

Man  of  54.  Eyes  closed  several  weeks  from  edema  of  the 
lids.  When  opened  again,  patient  was  blind.  Exophthalmos. 
Right  disc  white.  Vessels  indistinct,  lumen  normal.  Left, 
acute  neuro-retinitis.  Atrophy,  white  streaks  about  vessels. 
Later  vessels  obliterated  in  spots. — Lubinsky,  Klin.  Monatsbl. 
f.  Augenheilk.,  1878,  s.  168. 

Post-erysipelas,  two  cases  optic  atrophy.  In  a  third,  orbital 
abscess,  exophthalmos  L.  V.=0.  Pupil  dilated  ad  max.  Aque- 
ous hazy.  Optic  atrophy — R.  T.  -|-  4.  Choked  disc. — Hal- 
kermann,  Verlin  d.  Aerzte  des  Regier.  Augsberg,  32.  Ver- 
sammlung,  1894. 

Girl  of  16.  On  the  fourteenth  day  of  erysipelas,  exophthal- 
mos, ophthalmoplegia  externa,  dilatation  pupils,  media  clear. 
Amaurosis.  Retina  white,  vessels  slender,  discs  only  identi- 
fied by  vessels.  Orbital  abscess.  Slight  improvement  in  ocu- 
lar symptoms  before  death. — Ginguel,  Reciieil  d'Ophthah,  1879, 
p.  65.  ^  .      ^ 

I\Ian  of  40  with  lues.  On  the  fifth  day  of  erysipelas,  exoph- 
thalmos and  chemosis,  bilateral.  Myosis.  Amaurosis.  Corneal 
ulcer,  right,  due  to  exposure.  Ninth  day,  fundus,  left,  milky 
white.  A'essels  almost  reddish  black  and  three  times  normal 
size.  Extravasations.  Same  in  right  eye.  The  condition  of 
vessels  and  fundus  improved,  but  amaurosis  complete. — Knapp, 
Archiv.  f.  Augenheilk.,  B.  XIV,  s.  257. 

Man  of  36.  Edema  of  the  lids.  Orbital  abscess.  Amaurosis 
right.  Exophthalmos.  Impaired  rotation.  Disc  hazy,  vessels 
partially  converted  into  white  strands.  Exophthalmos  and 
chemosis  persisted  for  months.  In  two  years  the  vessels  had 
disappeared  all  but  a  few  white  streaks  and  two  trunks  filled 
with  blood.    Carl,  KHji.  Monafsbl.  f.  Augenheilk.,  1884,  p.  113. 

Pregnant  woman  of  41.  Edema  of  lids,  exophthalmos,  oph- 
thalmoplegia externa,  chemosis.  Orbital  abscess.  Pupil  did 
not  react.  Amaurosis.  Disc  hazy,  irregular  in  shape  and 
white.  Arteries  thread-like,  veins  distended.  Later,  vessels 
disappeared  almost  entirely. — Hoesch,  Ueber  Erkrankungen 
der  Gefasswandungen  in  der  Retina.     Berlin,  1881. 

Man  of  48.  Edema  of  lids,  exophthalmos,  ophthalmoplegia 
externa.  After  opening  the  lids  amblyopia,  and  objects  seen  in 
blue  fog.  Discs  marble-like  whiteness,  vessels  reduced.  Pig- 
ment epithelium  atrophic  along  the  vessels.  Necrotic  areas  of 
pigment  epithelium  between  macula  and  disc. — Herodes,  Zur 
Casuistik  der  Falle  von  Sehnerven  Atrophic  nach  Erysipel., 
Wiirzburg,   1888. 


ETIOLOGY  OF  ERYSIPELAS.  '    71 

Woman.  Double  exophthalmos,  right  amaurosis,  disc  and 
retina  atrophic.  Vessels  reduced. — Jager  Ophthalmoskop. 
Handatlas,  1869. 

Woman  of  28.  Edema  of  the  lids,  exophthalmos.  Anes- 
thesia inner  half  right  eyebrow.  Fifth  day  amaurosis  right 
eye.  After  five  months,  disc  white,  not  sharply  defined.  Ves- 
sels contracted  and  bordered  by  yellow  stripe,  empty  of  blood 
in  places. — Jager  1.  c.  Fig.  75,  Plate  XVI. 

Woman.  Edema  of  Hds,  bilateral  R.  conjunctiva  chem- 
osed.  Right  upper  lid  fluctuating.  Orbital  abscess.  x\mau- 
rosis.  Embolism  art.  cent.  ret.  Vessels  thread-like ;  disc  pale, 
whitish  haze.  Cherry-red  spots,  about  macula.  Four  weeks 
later,  total  optic  atrophy. — Emrys-Jones,  Brit.  Med.  Jour., 
1884,  Vol.  I,  p.  312. 

Following  erysipelas  a  unilateral  and  a  bilateral  blindness 
has  been  noticed.  In  the  latter  case,  in  the  left  disc  were  found 
beginning  atrophic  changes  ten  weeks  after  the  onset.  The 
arteries  were  narrowed  and  there  were  retinal  hemorrhages, 
and  later  hemorrhages  into  the  vitreous.  It  was  assumed 
that  the  orbit  had  been  slightly  inflamed. — Snell,  Ophthal.  Re- 
view, 1893,  p.  157.  Terrien  et  Sesne,  Archiv.  gener.  de  Medi- 
cine, 1903,  p.  2699. 

Erysipelatous  inflammation  of  the  orbit  where,  after  ex- 
tinction of  sight,  complete  restoration  occurred. — -v.  Graefe, 
cited  by  Lewin  &  Guillery,  Die  Wirkungen  von  Arztneimitteln 
und  Giften  auf  das  Auge,  Vol.  2,  p.  31.     Berlin,  1905. 

Man  of  25.  Erysipelas.  Pain  in  left  eye.  Edema  of  lids, 
exophthalmos,  chemosis,  amaurosis.  Same  condition  followed 
in  right  eye.  Left  fundus  not  visible.  Right,  narrowed  ar- 
teries and  unequal  venous  distribution.  Coma. — T.  40  degrees 
C.  Death.  P.  Isi.  Dififuse  purulent  infiltration  of  orbits.  Ab- 
scesses in  ocular  muscles  and  veins.  Sinus  thrombosis,  purulent 
meningitis,  purulent  pulmonary  infarcts.  The  infection  of  the 
right  orbit  seems  to  have  come  through  the  sinus  cavernosus. 
—Leber,  Archiv.  f.  Ophthalmol,  Vol.  XXVI,  Part  3,  p.  224. 

Man  of  21.  Erysipelas  followed  by  extreme  exophthalmos, 
orbital  abscess,  dilated  pupils,  amblyopia.  Ulcer  of  the  cornea, 
chemosis,  restricted  rotation.  Disc  white,  arteries  almost 
absent,  veins  tortuous.  Twenty-five  days  later,  left  otitis  media 
suppurativa  acuta.  Epileptiform  attacks.  Temporal  abscess. 
Death  in  six  months,  with  cerebral  disturbances.  Autopsy. 
Left  middle  convolution  was  a  mass  of  pus.    Tubercular  areas. 


72  ETIOLOGY  OF  ERYSIPELAS. 

Purulent  basilar  meningitis,  ostitis,  orbital  phlegmon.  Optic 
nerve  was  completely  replaced  by  developing  connecfive  tissue. 
The  vessels  were  open. — Panas,  Gazette  des  hopitaux,  1873, 
p.  1148. 

Woman.  Fourth  day  after  the  subsidence  of  an  erysipelas, 
terrific  pains  in  right  orbit.  Conjunctivitis.  In  forty-eight 
hours  edema  of  the  lids,  exophthalmos,  amaurosis,  cornea  hazy, 
ophthalmoplegia  externa,  pupil  fixed.  Left  eye  same  condition 
but  less  marked.  Cerebral  symptoms  and  death  on  sixth  day. 
Autopsy.  Both  orbits  infiltrated  with'  sero-purulent  fluid. 
Both  ophthalmic  veins  filled  with  pus.  Pus  in  sinus  cavernosus 
and  right  middle  cerebral  vein.— Poland,  Ophthal.  Hosp.  Re- 
ports, Vol.  I,  1857,  p.  26. 

Woman  of  60.  Comatose  14  days.  Edema  of  lids.  No 
exophthalmos,  but  pain  in  the  eyes.  Eyes  not  seen  for  4  weeks. 
Then  left  eye  amaurotic.  Right  eye  normal.  Symblepharon 
left  lower  lid.  Left  pupil  one-half  dilated.  Disc  flattened, 
greyish  white  discoloration.  Arteries  reduced,  some  oblit- 
erated.— Schenke,  Prag.  med.  Wochensch.,  B.  IIL  No.  23,  s. 
229. 

Woman  of  59.  Rapid  diminution  of  vision,  bilateral,  after 
erysipelas  one  year  previously.  Fingers  at  20  c.  m.  Discs 
atrophic,  greyish  white,  slightly  excavated.  Vessels  normal. 
Choroid  atrophic  near  disc  margin. — Parinaud,  Archives  de 
med.,  1^79.    7  ser.,  T.  3,  p.  644. 

Man  of  54.  Enormous  edema  of  lids.  Orbital  abscess. 
Total  bilateral  amaurosis.  Death  in  four  months.  Autopsy ; 
lids,  orbit  and  globe  normal.  No  bacteria.  Both  optic  nerves 
oval  at  optic  foramina  and  spongy.  Nasal  portion,  yellowish 
grey;  temporal,  greyish  white.  Pronounced  increase  of  con- 
nective tissue  in  temporal  portion ;  nasal  part  retained  its 
neuroglia.  Central  vessels  normal. — ^Lewin  and  Guillery, 
1.  c. 

Woman  of  26.  Erysipelas  lasting  ten  days.  Then  severe 
headache,  fever  and  failure  of  vision  to  absolute  amaurosis  on 
eighteenth  day.  After  forty-eight  hours  improvement  of  vision, 
but  visual  hallucinations.  Floor  gave  reflection  like  a  mirror 
and  from  an  excavation  in  it  flames  burst  forth.  In  six 
weeks  counted  fingers  at  1  m.  Concentric  contraction  F.  V. 
bilateral.  Central  scotoma,  left.  Discs  atrophic.  Vessels  nor- 
mal. V.  improved  to  1/5. — Parinaud,  Arch,  generale  de  med. 
1879,  7  ser.  T.  3,  Juin,  p.  641. 


ETIOI^OGY  OF  ERYSIPELAS.  73 

Woman  of  26.  Recovery  from  erysipelas.  Then  deafness 
and  amblyopia.  Fourteen  days  later  dilated  pupils.  Seventeen 
days  "amaurosis,  right.  V.  was  completely  restored  in  four 
weeks. — Durioziez  bei  Gubler,  Arch.  gen.  de  med.,  5  ser.,  T. 
XV,  1860,  s.  698. 

Woman  of  30.  Following  erysipelas,  headache,  deafness  of 
the  right  ear,  dense  haze  in  right  eye,  cloudiness  left  eye, 
choreiform  disturbances  arms  and  legs,  red  flashes  right  eye. 
In  eight  weeks  the  eyes  had  very  much  improved.  The  other 
disturbances  continued. — Durioziez  bei  Gubler,  1.  c.  p.  703. 

Woman  of  32.  Third  attack  of  erysipelas.  As  sequelae 
great  asthenia  and  anemia.  Choreic  twitching  of  head  and 
progressive  amblyopia  to  complete  amaurosis.  Pupils  dilated 
and  fixed.  In  a  year  the  visual  disturbances  had  disappeared. — 
Bourdon  bei  Gubler,  1.  c.  s.  699. 

Man  of  40.  Severe  exposure  during  an  attack  of  erysipelas 
Twenty-four  hours  later  amblyopia.  y:rzl/7  Jag.  No.  17. 
Slight  concentric  contraction  F.  V..  Central  scotoma.  Venous 
hyperemia  of  fundus.  Recovery  in  five  or  six  months. — Thier, 
Klin.  Monatsbl.  f.  Augenh.,  1900,  s.  643. 

Girl  of  16.  Edema  right  upper  lid.  Fourth  day  complete 
amaurosis.  Pupil  dilated  but  reacted.  Disc  hazy  margin. 
Vessels  narrowed.  Fifteenth  day  ophthalmoscopic  examination 
negative.  V=motion  of  hand.  Three  days  later  changes  in 
F.  V.  V=fingers  at  12  ft.  Rapid  improvement.  Twenty-fifth 
day  complete  recovery. — Weiland,  Deutsche  med.  Wochen- 
schr.,  1886,  No.  39. 

Man  of  32.  History  excessive  alcoholism.  Erysipelas  with 
coma  for  nine  days.  After  recovery,  severe  headache,  failing 
vision.  L.  V.=fingers  }^  metre.  F.  V.  normal.  Nyctalopia. 
Left  disc  injected,  hazy.  Haze  over  retina  with  distended  veins 
and  reduced  arteries.  Tenderness  on  pressure  or  movement 
of  globe.  Later  neuro-retinitis  in  right  eye.  In  fortnight  slight 
improvement ;  in  five  weeks  complete  recovery  right  and  left. — 
Vossius,  Klin.  Monatsbl.  f.  Augenheilk'.,  1883,  s.  294. 

Man  of  19.  Recurent  erysipelas  of  right  side.  A  few  months 
later  vision  failed.  V=2/10.  After  another  attack  R.  V.= 
20/200,  L.  V.=l.  Haziness  of  vitreous,  retinal  detachment, 
macular  hemorrhage,  yellow  plaques.  Picture  that  of  nephritic 
retinitis.  Later  marked  improvement.  V:=almost  2/3.  In  two 
days  relapse.  Fundal  picture  much  as  before.  V=fingers  at 
14  ft.     F.  V.  reduced.     Again,  improvement,     In  six  months 


74  ETIOIvOGY  OF  ERYSIPELAS. 

another  relapse  of  erysipelas  with  failure  of  vision.  Atrophic 
changes  in  fundus.  Excentric  scotoma.  V=20/50.  Later  V=: 
20/30. — Vossius,  Klin.  Monatsbl.  f.  Augenheilk.,  1880,  s.  410. 

On  account  of  a  purulent  cyclitis  with  unendurable  pain, 
enucleation  had  to  be  done  in  one  case.  A  hyaloiditis  duplex 
which  had  been  caused  by  erysipelas  required  a  paracentesis 
and  a  culture  of  S.  erysipelatis  was  obtained  from  the  aqueous 
humor.  (Compare  Hoesch,  Vossius,  Fetzer,  Hallerman,  1. c, 
and  Hausen  (Nord.  Ophth.  Tijdschr.,  T.  IV,  p.  29)  who  ob- 
served a  case  of  severe  erysipelatous  plastic  iritis  with  con- 
siderable exudate  on  the  anterior  lens  capsule  which  termi- 
nated favorably.) — Fortunati,  Reforma  medica,  Ottobre,  1889. 

Wagenmann  found  streptococci  in  the  arterioles  of  a  patient 
suffering  from  albuminuric  retinitis  who  had  died  from  ery- 
sipelas.— Sitzungsherichte  der  Ophth.  Gesellsch.  Heidelberg, 
1896.     Discussion  zu  Axenfeld. 

Man  of  26.  During  convalescence  from  erysipelas  there  ap- 
peared headache,  fever,  contracted  and  fixed  pupils,  coma 
with  dilated  pupils,  left  hemiparesis  and  deafh  in  22  days.  A 
seropurulent  secretion  was  found  in  the  lateral  ventricles  and 
a  meningitis  of  the  frontal  lobe  of  the  right  hemisphere,  throm- 
bosis of  the  sinus  cavernosus  and  of  the  right  ophthalmic  vein. 
Lewin  and  Guillery,  1.  c. 

Streptococci  were  found  in  an  eye  which  suddenly  developed 
panophthalmitis  without  assignable  cause ;  the  culture  of  the 
S.  resembled  pneumococci  closely.  The  vitreous  was  infil- 
trated with  pus,  the  arteries  thickened.  The  retina  was  de- 
stroyed. In  front  of  it  were  masses  of  cocci  and  zooglea.  The 
patient  had  frequently  suffered  from  recurrent  erysipelas. — 
Axenfeld,  1.  c. 

Woman  of  46.  Repeated  attacks  of  erysipelas.  Developed 
visual  disturbances  after  last  attack.  R.  V.:=fingers  at  30 
cm.,  L.  V.=fingers  1  m.  Hyaloiditis  duplex.  Floating  opaci- 
ties. Fundus  invisible.  Paracentesis  gave  cultures  of  strepto- 
cocci in  48  hours. — Gillete  de  Gramont,  Bull,  et  mem.  de  la  Soc. 
francaise  de  Ophthalm.,  T.  X.,  1892,  p.  285. 

A  septic  embolus  of  the  right  eye  developed  due  to  erysip- 
elas. There  were  swelling  of  the  lids,  circumcorneal  injec- 
tion, tenderness  of  the  ciliary  region,  hypopyon,  haziness  of 
the  vitreous  T.+2.  Vision  lost.  Death  on  twenty- fourth  day. 
Orbital  involvement  could  not  be  demonstrated. — Cornwell, 
Medical  Record,  1882,  August  12th. 


ETIOLOGY  OF  ERYSIPEIvAS.  75 

A  patient  of  45  who  had  had  prodromal  symptoms  of  glau- 
coma for  a  long  time  developed  erysipelas  after  leeches  and 
atropin  had  been  used.  An  acute  glaucoma  developed  in  both 
eyes  after  a  few  days.  Outcome  bad  despite  the  fact  that  iridec- 
tomy had  been  made.  Another  case  developed  facial  erysip- 
elas six  days  after  an  iridectomy  for  glaucoma.  This  opera- 
tion was  also  unsuccessful. — Galezowski,  Recueil  d'Ophthal., 
1876,  p.  202.  Other  cases  are  reported  with  a  more  favorable 
outcome. — Magauky,  Peterb.  medic.  Wochenschr.,  1890,  s.  301. 

Man  of  20.  After  erysipelas,  sudden  paralysis  of  the  nerves 
of  the  superior  branch  of  trigeminus.  Slight  exophthalmos: 
Recovery  after  inunction,  although  no  evidence  of  lues.  /Vfter 
several  weeks  a  sudden  transient,  complete  paralysis  of  left 
oculomotor.  Chronic  meningitis  with  orbital  phlegmon  and 
hemorrhage  in  the  vicinity  of  the  superior  orbital  fissure  were 
given  as  causes. — Stoener,  Munch,  med.  Wochensch.,  1892,  s. 
863. 

Girl  of  18.  During  and  after  an  attack  of  erysipelas,  uni- 
lateral  paresis   of   accommodation. — Schmidt-Rimpler,   1.   c. 

Personal  Communications  of  Damage  to  the  Bye  and  Bar  from 
Members  of  the  American  Laryngological  Society,  Ameri- 
can Otological  Society,  American  Academy  of  Ophthal- 
m,ology  and  Oto-Laryngology,  and  American  Ophthalmo- 
logical  Society. 

David  Coggin,  Salem. — One  case  of  loss  of  vision  of  both 
eyes  after  erysipelas. 

D.  W.  Greene,  Dayton. — -Case  of  erysipelas  following  teno- 
tomy of  internal  rectus  of  right  eye.  Loss  of  vision  from 
atrophy  of  optic  nerve. 

F.  P.  Capron,  Providence. — "A  very  few  cases  of  ocular 
trouble  due  to  erysipelas,  but  no  record  of  the  causes  of  the 
erysipelas." 

Wm.  L.  Wood,  Portland,  Ore. — One  case  of  facial  erysipe- 
las in  which  the  cornea  of  each  eye  was  destroyed.  The  origin 
of  the  erysipelas  was  not  traced  to  diseased  nasal  chambers. 

Walter  R.  Parker,  Detroit. — Two  cases  of  glaucoma  in  the 
course  of  facial  erysipelas.  Both  recovered  without  opera- 
tion, although  had  there  been  no  erysipelas,  Parker  would 
have  advised  immediate  iridectomy  in  both  cases. 

Herbert  Harlan,  Baltimore. — One  case  inflammation  of  the 
eye  of  a  young  woman.     Facial  erysipelas   following  severe 


76  ETIOI.OGY   OF  ERYSIPELAS. 

conjunctivitis  (probably  streptococcus  infection).  Another 
similar  case.  Physician,  aged  67.  Conjunctivitis  of  unknown 
cause.  Rather  severe  erysipelas  on  right  side  with  great  ede- 
ma of  lids  of  both  eyes.  Now  under  treatment  and  rapidly 
subsiding.    No  permanent  damage  to  eye  in  either  case. 

R.  S.  Lamb,  Washington. — Has  seen  a  number  of  cases  in 
which  more  or  less  extensive  damage  was  done  to  the  eye  as 
the  result  of  an  attack  of  facial  erysipelas,  but  as  they  were 
clinic  and  dispensary  cases,  he  has  no  records. 

J.  C.  Easton,  Springfield,  O. — Facial  erysipelas.  Edema  of 
lids,  sloughing  tissues  near  inner  canthus.  Orbital  abscess. 
Conjunctivitis.  Ulcus  corneae.  Recovery  with  slight  haziness 
of  cornea  and  slight  retraction  of  upper  lid. 

John  E.  Weeks,  New  York. — One  case  of  blindness  in  both 
eyes  due  to  erysipelas  extending  from  face  to  orbits.  Reduc- 
tion of  size  of  retinal  arteries.  Thrombosis  of  veins.  Subse- 
quent optic  nerve  atrophy.  Patient,  male  32  years.  Erysipelas 
apparently  extended  from  nasal  mucous  membrane.  One  case 
blindness  in  one  eye  following  facial  erysipelas  of  unknown 
origin.  Patient,  female,  24  years  of  age.  Erysipelas  most 
severe  on  right  side  of  face.  Right  eye  blind.  Arteries  small, 
veins  thrombosed.     Nerve  eventually  atrophied. 

W.  H.  Peters,  LaFayette. — "In  the  cases  I  have  seen  there 
has  been  chronic  hypertrophic  rhinitis.  The  patients  have  con- 
sulted me  for  tear  sac  trouble." 

Jas.  W.  Ingalls,  Brooklyn. — Case  I. — Erysipelas  affected 
both  sides  of  face — blindness  of  both  eyes  resulted.  Soon  died 
of  pneumonia.  Case  II. — Facial  erysipelas  caused  blindness 
of  one  eye.  There  was  no  sinus  trouble.  Case  III. — Slough- 
ing (partial)  of  both  upper  lids.  Sight  not  affected  to  any 
extent.     No  disease  of  accessory  cavities  as  far  as  known. 

L.  R.  Ryan,  Galesburg. — 'Woman  of  70  years  operated 
upon  for  senile  cataract.  Erysipelas  developed  within  24  hours, 
involving  nose,  cheeks  and  forehead.  Cornea  sloughed  and 
eye  was  lost.  I  afterward  discovered  pus  deep  in  duct,  also 
some  involvement  of  the  ethmoid.  Case  was  undoubtedly  of 
nasal  origin." 

H.  M.  Fish,  Case  I. — "A  lady  patient,  whose  vision  I  knew 
to  be  normal,  complained  of  a  reduction  of  vision  and  redness 
and  swelling  of  the  upper  lid,  noted  the  day  before ;  there  had 
been  some  pain  and  trouble  about  the  eye  for  several  days. 
Marked  violet-colored  swelling  of  the  upper  lid  and  internal 


ETIOLOGY   OF  ERYSIPELAS.  77 

angle  of  the  orbit;  pain  on  pressure  under  the  frontal  sinus. 
Media  clear;  disc  edematous,  its  margins  obscured.  V.= 
10/20.  In  the  middle  meatus  a  mucopurulent  secretion. 
Syringing  the  frontal  sinus  brought  about  complete  restora- 
tion and  normal  vision  in  a  few  days'  time."  Case  II.- — ''A 
patient  recently  consulted  me  for  unilateral  amaurosis,  a  com- 
plete optic  atrophy,  that  followed  an  attack  of  facial  erysipelas 
several  years  ago.  *  *  Nasal  examination  showed  a  chronic 
"atrophic  rhinitis" — the  misnomer  for  an  accessory  sinus  dis- 
ease in  only  too  many  cases.  In  this  case  an  accessory  sinus 
disease  was  probably  the  primary  lesion,  the  facial  erysipelas 
and  optic  atrophy  secondary  thereto.  In  my  opinion  the  veri- 
table pathogenesis  in  the  great  majority  of  non-traumatic  ery- 
sipelas-ocular cases  is  a  strepto-  or  staphylococcic  infection  of 
a  nasal  accessory  sinus  or  the  upper  nares  with  propagation  to 
the  orbit,  cranium  or  subcutaneous  tissue." 

Joseph  C.  Beck,  Chicago. — Case  of  facial  erysipelas  starting 
at  ala  nasi.  Involvement  of  eye.  Conjunctivitis,  keratitis, 
ulcus  cornea.     Termination,  leucoma  cornea. 

Edward  Jackson,  Denver.— "I  have  seen  glaucoma  and  op- 
tic atrophy  from  facial  erysipelas,  besides  orbital  cellulitis  and 
inflammation  of  the  lids.  But  I  have  not  traced  the  erysipelas 
to  disease  of  the  nose  or  its  accessory  sinuses." 

Joseph  A.  Andrews,  Santa  Barbara. — Case  of  erysipelas  de- 
veloping after  abrasion  and  possible  fracture  of  nose.  Edema 
of  lids,  orbital  cellulitis,  exophthalmos.  Death  in  two  or  three 
days  from  meningitis. 

Allen  Greenwood,  Boston. — "Recent  case  of  facial  erysip- 
elas developed  severe  phlegmon  of  the  orbits  with  proptosis 
and  destruction  of  both  eyes  and  upper  lids.  Death.  Origin 
of  erysipelas  not  determined." 

Frank  R.  Spencer,  BouMer — Case  of  facial  erysipelas.  Man 
aged  70,  with  carcinoma  of  liver  and  interstitial  nephritis. 
Erysipelas  extended  to  the  cellular  tissue  of  right  orbit.  Prop- 
tosis and  convergence,  chemosis,  lids  edematous,  cornea  and 
media  hazy,  hypopyon.  Fluctuation  upper  external  angle  or- 
bit. Incision  liberated  8  cc.  pus.  Panophthalmitis.  Coma 
and  death  one  week  later. 

H.  Bert  Ellis,  Los  Angeles. — Sailor,  aged  54  years.  Daciyo- 
cystitis.  Erysipelas.  Severe  case.  Panophthalmitis.  Subse- 
quent enucleation.  Man  aged  57.  Carpenter  with  onlv  one 
eye.     Developed  erysipelas  after  slight  injury  of  cheek.     Orbit 


78  ETIOLOGY  OF  ERYSIPELAS. 

of  only  eye  involved.  Lids  board-like  on  second  day.  Exter- 
nal canthotomy  and  opened  several  abscesses  in  lids.  Gave  80 
cc.  streptolytic  serum.  Patient  unable  to  move  eyeball,  saw- 
flashes  of  light  and  was  delirious.  Recovery  complete  in  eight 
days.     Patient  a  sufferer  from  chronic  atrophic  rhinitis. 

L.  L.  Doane,  Butler,  Pa. — Case  I. — Man,  aged  24.  Seen  in 
consultation  on  eighteenth  day  of  facial  erysipelas.  Latter 
began  at  nose.  Face  enormously  swollen.  Many  abscesses 
scalp  and  lids.  Pus  in  left  orbit.  Evacuated.  Recovery.  V= 
1/2,  right,  fingers  at  six  feet,  left,  without  correction.  Right 
normal  with  correction,  left  only  improved  a  little.  Case  II. — 
Young  married  w^oman.  Phlegmonous  erysipelas  of  orbit  and 
face.  Incised  orbit,  no  pus.  Recovery.  V=better  than  1/5 
in  affected  eye  and  still  improving. 

H.  M.  Ray,  Louisville,  Ky. — Man,  aged  60.  Slight  wound 
of  eyebrow.  Facial  erysipelas,  orbital  cellulitis,  optic  neuritis 
and  neuro-retinitis  terminating  in  atrophy  of  optic  nerve  and 
complete  loss  of  vision.  One  case  optic  nerve  atrophy  which 
was  said  to  have  followed  injury  and  facial  erysipelas,  as  in 
above  case. 

M.  H.  Post,  St.  Louis.— One  or  two  cases  years  ago  where 
atrophy  of  the  optic  nerve  followed  facial  erysipelas. 

Jas.  F.  McKernon,  New  York. — Female,  aged  17  years. 
Destruction  of  portions  of  both  eyelids.  Sight  improved  some- 
what later  on.  Supposed  erysipelatous  infection  from  old  sup- 
puration of  middle  ear. 

Edw.  A.  Shumway,  Philadelphia. — Several  cases  of  orbital 
cellulitis  during  attacks  of  facial  erysipelas. 

Robert  Sattler,  Cincinnati. — Two  cases  of  unilateral  optic 
nerve  atrophy  result  of  facial  erysipelas,  but  could  not  trace 
cause  to  intranasal  disease. 

J.  A.  Stuckey,  Lexington,  Ky. — In  two  cases  of  erysipelas 
following:  (1)  frontal,  and  (2)  ethmoidal  disease,  the  eye  was 
seriously  threatened,  but  no  permanent  injury  resulted. 

Oscar  Dodd,  Chicago. — Wound  of  Hd.  Erysipelas  orbital 
abscess.    Blindness  from  optic  nerve  atrophy. 

E.  S.  Strout,  Minneapolis. — Facial  erysipelas.  Abscess  of 
upper  eyelid  resulting  in  considerable  deformity,  which  gradu- 
ally disappeared. 

Eugene  Smith,  Detroit. — Sloughing  of  skin  of  upper  lid  and 
panophthalmitis. 

M.  V.  Hall,  Warren,  Pa. — Great  edema  of  orbital  tissues, 


ETIOLOGY   OF  ERYSIPELAS.  79 

Vision  nil.  Death  from  pyemia  and  thrombosis  of  cavernous 
sinus. 

C.  A.  Veazey,  Philadelphia. — Two  cases  of  optic  nerve 
atrophy. 

P.  M.  Farrington,  Memphis. —  (1)  Exophthalmos  and  oph- 
thalmoplegia externa.  Death.  (2)  Exophthalmos  and  oph- 
thalmoplegia externa.  Thrombosis  of  the  transverse  sinus. 
Death. 

Thos.  F.  Kellar,  Toledo. — Exophthalmos  and  ecchymosis 
conjunctivae  with  each  recurrent  attack.  Empyema  antrum  of 
Highmore. 

F.  C.  Hotz,  Chicago. — One  case  optic  nerve  atrophy  fo' low- 
ing erysipelas. 

E.  C.  Ellett,  Memphis. — One  fatal  case  of  erysipelas  in 
which  the  eyeHds  sloughed.  One  case  in  which  skin  of  left 
upper  lid  sloughed,  but  not  enough  to  cause  deformity.  Latter 
case  had  left  frontal  sinus  and  antral  suppuration  two  years 
after  the  attack  of  erysipelas  noted. 

Wm.  Merle  Carhart,  New  York. — Erysipelatous  infection 
extended  to  right  eye,  causing  orbital  cellulitis.  Phlegmon 
was  opened,  but  corneal  ulcers  and  panophthalmitis  followed. 
Infection  extended  to  cranial  cavity.  Death  from  meningitis. 
Erysipelas  followed  nasal  disease. 

Jas.  A.  Spalding,  Portland,  Me. — Two  cases  seen  in  consul- 
tation. Men  over  50  years,  both  blind  with  optic  atrophy  in 
each  eye.  Alleged  cause  was  erysipelas  of  eyelids  and  fore- 
head. No  apparent  cause  except  extremely  cold  weather. 
Both  men  were  hostlers.  Erysipelas  may  have  been  due  to 
rubbing  foreheads  and  eyelids  with  unclean  hands  after  at- 
tending to  horses. 

Chas.  Adams,  Trenton. — Woman,  aged  47.  Sloughing  of 
cornea,  prolapse  of  iris.  Severe  and  constant  pain  in  phthisical 
bulb.  Enucleation.  T.  S.,  aged  50.  Insane  asylum.  Ery- 
sipelas involving  cornea  of  right  eye.  Death  in  a  few  days 
from  meningitis. 

E.  A.  Kegley,  Cedar  Rapids.— ^Corneal  ulcers  due  to  an  at- 
tack of  facial  erysipelas.     Chronic  dacryocystitis. 

L.  Haynes  Buxton,  Oklahoma  City. — Robust  girl  of  18  years, 
with  history  of  perfect  health.  Facial  erysipelas  complicated 
by  secondary  mastoiditis.    Death  from  meningitis. 

F.  L.  Henderson,  St.  Louis. — Furuncle  at  end  of  nose.  Fa- 
cial  erysipelas,  orbital   cellulitis.     Thrombosis   cavernous   and 


80  eTiOLOGY  OF  ERYSIPEIvAS. 

lateral  sinuses.  Death.  No  disease  of  nose  or  accessory  si- 
nuses. 

Wm.  R.  Dabney,  Marietta,  O. —  (1)  Thrombosis  of  central 
vein  of  retina  in  both  eyes.  Death  from  extension  to  the  men- 
inges. Chronic  bilateral  pansinusitis.  (2)  Complete  atrophy 
of  both  optic  nerves.     Chronic  bilateral  antral  suppuration. 

W.  F.  Mittendorf,  New .  York. — One  case  orbital  abscess. 
Two  cases  sloughing  of  lower  lids. 

C.  Barck,  St.  Louis. — Three  cases  atrophy  optic  nerve,  end- 
ing in  blindness. 

D.  E.  Esterly,  Topeka, —  (1)  First  attack  of  erysipelas  fol- 
lowed by  ectropion  lower  lid.  Second  attack  by  perforating 
ulcer  cornea.  Iridocyclitis,  etc.  Enucleation.  (2)  Cicatricial 
ectropion  left  lower  lid  following  erysipelas,  Septal  perfora- 
tion. Hypertrophied  lower  turbinate.  Hypertrophied  middle 
turbinate  with  polypoid  condition. 

W.  Cheatham,  Louisville,  Ky. — ^Case  of  acute  middle  ear 
suppuration  in  the  course  of  erysipelas. 

Edw.  J.  Bernstein,  Kalamazoo. — Serpiginious  ulcer  of  cor- 
nea which  showed  signs  of  healing  before  fatal  termination  of 
case. 

G.  E.  deSchweinitz,  Philadelphia. — "I  have  seen  a  good 
many  ocular  diseases  directly  traceable  to  facial  erysipelas.  I 
do  not  know  whether  in  any  one  of  these  instances,  however, 
there  was  a  positive  relationship  noted  between  the  attack  of 
erysipelas  and  the  disease  of  the  sinuses  or  nasal  chambers." 

H.  F.  Hansell,  Philadelphia. — "A  number  of  cases  have  re- 
quired enucleation  of  the  eye  as  a  result  of  extension  of  facial 
erysipelas  into  the  orbital  tissues,  others  have  had  permanent 
loss  of  vision  from  atrophy  of  the  optic  nerve.  In  none  was  the 
cause  traced  to  diseased  nasal  chambers  or  accessory  sinuses. 
Most  of  the  cases  were  fatal." 

C.  R.  Holmes,  Cincinnati,  O. — Man,  aged  46.  History  of 
alcoholic  excesses.  Pansinusitis,  R.  &  L-  Chronic  case  with 
frequent  exacerbations  of  inflammations  in  frontals.  External 
operation  opening  both  frontal  sinuses  during  acute  attack. 
Erysipelas  followed  immediately.  Severe  attack  lasting  two 
weeks.    Corneal  ulcer. 

Louis  J.  Goux,  Detroit. — One  case  of  facial  erysipelas,  due 
to  infection  through  ulcer  of  septum.  Acute  attack  of  double 
otitis  media. 

Thos.  Hubbard,  Toledo. — "One  case  in  which  general  facial 


ETIOLOGY  OF  ERYSIPELAS.  81 

erysipelas  originated  in  nares,  causing  a  probable  acute  sinus 
infection  and  very  severe  eye  involvement.  There  was  more 
or  less  destruction  of  conjunctiva  and  even  keratitis  with  areas 
of  opacity,  but  function  was  not  materially  impaired." 

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